Deficiency Records for Otterbein St Marys Retirement Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Otterbein St Marys Retirement Community. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-01-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-14 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-12-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-14 | 2023-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-14 | 2023-10-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-14 | 2023-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-11 | 2023-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-10 | 2021-07-20 | 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 | 2021-06-10 | 2021-07-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-10 | 2021-07-20 | 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 | 2021-06-10 | 2021-07-20 | 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 | 2021-06-16 | 2021-07-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-16 | 2021-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-16 | 2021-07-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-21 | 2019-04-05 | 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 | 2019-02-21 | 2019-04-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-21 | 2019-04-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-21 | 2019-04-05 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-21 | 2019-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-21 | 2019-04-05 | 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 | 2019-02-21 | 2019-04-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-02-21 | 2019-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-21 | 2019-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-21 | 2019-04-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-02-19 | 2019-04-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-02-19 | 2019-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-19 | 2019-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-19 | 2019-04-05 | N |
