Deficiency Records for St Mary's Center For Rehabilitation and Healthcare
Updated as of April 01, 2024
A list of the most recent deficiencies for St Mary's Center For Rehabilitation and Healthcare. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-11-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-19 | 2023-11-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-19 | 2023-11-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-11-27 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-19 | 2023-11-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-19 | 2023-11-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-19 | 2023-11-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-11-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-19 | 2023-11-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-19 | 2023-11-27 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-10-19 | 2023-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-11-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-11-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-19 | 2023-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-19 | 2023-11-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-19 | 2023-11-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-19 | 2023-11-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-19 | 2023-11-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-21 | 2022-08-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-21 | 2022-08-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-21 | 2022-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-21 | 2022-08-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-21 | 2022-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-21 | 2022-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-21 | 2022-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-21 | 2022-07-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-21 | 2022-07-29 | 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 | 2022-06-21 | 2022-07-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-21 | 2022-07-29 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-06-21 | 2022-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-21 | 2022-07-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-31 | 2020-03-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-31 | 2020-03-13 | 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 | 2020-01-31 | 2020-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-31 | 2020-03-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-31 | 2020-03-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-31 | 2020-03-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-31 | 2020-03-13 | N |
