Deficiency Records for St Mary Center For Rehabilitation and Healthcare
Updated as of January 01, 2022
This is not the most recent data for St Mary Center For Rehabilitation and Healthcare. For the most recent information, click here.
A list of the most recent deficiencies for St Mary 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 | 2021-04-26 | 2021-06-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-04-26 | 2021-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-26 | 2021-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-26 | 2021-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-26 | 2021-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-26 | 2021-06-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-23 | 2021-05-26 | 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 | 2021-04-23 | 2021-05-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-25 | 2020-03-18 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2020-01-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-12-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-10 | 2019-11-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-10 | 2019-11-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-10 | 2019-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-10 | 2019-11-25 | 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 | 2019-10-10 | 2019-11-25 | 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 | 2019-10-10 | 2019-11-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-10 | 2019-11-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-01 | 2019-05-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-01 | 2019-05-03 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-26 | 2019-01-25 | 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 | 2018-11-26 | 2019-01-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-26 | 2019-01-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-11-09 | 2018-12-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-09 | 2018-12-31 | 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 | 2018-11-09 | 2018-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-09 | 2018-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-09 | 2018-12-31 | 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 | 2018-11-09 | 2018-12-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-09 | 2018-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-09 | 2018-12-31 | N |
