Deficiency Records for St Monica Center For Rehabilitation and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for St Monica 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-01-04 | 2024-01-30 | 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 | 2024-01-04 | 2024-01-30 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-04 | 2024-01-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-04 | 2024-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-04 | 2024-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-01-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-04 | 2024-01-30 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-07 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-07 | 2023-12-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2023-12-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2023-12-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-07 | 2023-12-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-07 | 2023-12-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-07 | 2023-12-28 | N |
| 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 | 2023-12-07 | 2023-12-28 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-07 | 2023-12-28 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-12-07 | 2023-12-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-07 | 2023-12-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-07 | 2023-12-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-07 | 2023-12-28 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-05 | 2023-10-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-11 | 2023-10-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-24 | 2023-08-22 | Y |
| Provide appropriate foot care. | Health | 2023-07-24 | 2023-08-22 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-08 | 2023-04-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-27 | 2023-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-27 | 2023-04-04 | N |
| Report COVID19 data to residents and families. | Health | 2023-02-27 | 2023-04-04 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-27 | 2023-04-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-27 | 2023-04-04 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2023-02-27 | 2023-04-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-27 | 2023-04-04 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-02-27 | 2023-04-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-27 | 2023-04-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-19 | 2023-02-01 | Y |
| Develop a communication plan. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-06 | 2022-05-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-23 | 2022-05-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-23 | 2022-05-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-23 | 2022-05-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-23 | 2022-05-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-23 | 2022-05-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-03 | 2021-09-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-03 | 2021-09-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-03 | 2021-09-03 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-03 | 2021-09-03 | Y |
