A list of the most recent deficiencies for St Margarets Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-05 | 2023-11-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-05 | 2023-11-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-27 | 2023-08-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-27 | 2023-08-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-27 | 2023-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-10 | 2023-02-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-09-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-29 | 2022-08-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-28 | 2022-07-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-28 | 2022-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-07-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-29 | 2022-07-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-06-29 | 2022-07-19 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-28 | 2022-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-21 | 2022-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-21 | 2022-04-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-21 | 2022-04-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-21 | 2022-04-22 | Y |
| 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 | 2022-03-21 | 2022-04-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-21 | 2022-04-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-16 | 2022-01-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-16 | 2022-01-14 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-16 | 2022-01-14 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-12-16 | 2022-01-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-06-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-04-28 | 2021-06-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-08 | 2021-05-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-11 | 2020-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-11 | 2020-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-11 | 2020-04-03 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-11 | 2020-04-03 | 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 | 2019-03-13 | 2019-04-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-13 | 2019-04-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-13 | 2019-04-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-13 | 2019-04-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-13 | 2019-04-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-13 | 2019-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-13 | 2019-04-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-03-13 | 2019-04-29 | N |
| Dispose of garbage and refuse properly. | Health | 2019-03-13 | 2019-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-13 | 2019-04-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Ensure gas and vacuum piping is labeled. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-03-13 | 2019-04-29 | N |
