A list of the most recent deficiencies for Vancrest of St Mary's. 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? |
|---|---|---|---|---|
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-11-22 | 2023-12-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-22 | 2023-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-22 | 2023-12-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-22 | 2023-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2023-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2023-12-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-20 | 2023-12-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-22 | 2021-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-22 | 2021-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-19 | 2021-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-19 | 2021-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-19 | 2021-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-19 | 2021-08-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-18 | 2019-06-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-18 | 2019-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-06-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-18 | 2019-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-18 | 2019-06-07 | 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 | 2019-04-18 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-06-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-18 | 2019-06-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-04-15 | 2019-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-15 | 2019-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-15 | 2019-06-07 | N |
