A list of the most recent deficiencies for Ignite Medical Resort St Marys LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-25 | 2022-12-09 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-10-25 | 2022-12-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-25 | 2022-12-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-10-25 | 2022-12-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-25 | 2022-12-09 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-25 | 2022-12-09 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-25 | 2022-12-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-25 | 2022-12-09 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-03-15 | 2021-03-26 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-14 | 2020-03-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-14 | 2020-02-27 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-01-14 | 2020-02-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-14 | 2020-02-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-14 | 2020-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-14 | 2020-02-27 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-14 | 2020-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-14 | 2020-02-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-14 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-14 | 2020-02-27 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-14 | 2020-02-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-01-14 | 2020-02-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-14 | 2020-02-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-14 | 2020-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-14 | 2020-02-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-28 | 2019-04-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-28 | 2019-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-28 | 2019-04-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-28 | 2019-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-04-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-02-28 | 2019-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-28 | 2019-04-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-28 | 2019-04-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-28 | 2019-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-28 | 2019-04-18 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-28 | 2019-04-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-28 | 2019-04-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-28 | 2019-04-18 | N |
