A list of the most recent deficiencies for Mt Alverna Home Inc. 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-14 | 2024-01-31 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-12-14 | 2024-01-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-19 | 2022-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-07 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-07 | 2022-07-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-06-07 | 2022-07-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-07 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-07-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-18 | 2022-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-16 | 2021-12-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-16 | 2021-12-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-07 | 2021-09-30 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-16 | 2019-10-25 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-07-18 | 2019-10-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-18 | 2019-10-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-18 | 2019-10-09 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-18 | 2019-10-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-18 | 2019-10-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-18 | 2019-10-09 | 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 | 2019-07-18 | 2019-10-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-18 | 2019-10-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-16 | 2019-10-09 | 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 | 2019-07-16 | 2019-10-09 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-07-16 | 2019-10-09 | 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 | 2019-07-16 | 2019-10-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-16 | 2019-10-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Develop a communication plan. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-07-16 | 2019-09-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-07-16 | 2019-09-06 | 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 | 2018-06-14 | 2018-08-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-14 | 2018-08-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-14 | 2018-08-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-06-12 | 2018-08-03 | N |
