A list of the most recent deficiencies for St Clare Health and Rehab, LLC. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-09 | 2021-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-09 | 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 | 2021-06-07 | 2021-07-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-07 | 2021-07-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-09 | 2021-07-15 | 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 | 2021-06-09 | 2021-07-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-10 | 2019-05-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-10 | 2019-05-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-10 | 2019-05-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-10 | 2019-05-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-10 | 2019-05-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-10 | 2019-05-25 | 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 | 2019-04-10 | 2019-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-10 | 2019-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-10 | 2019-05-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-08 | 2019-05-25 | 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 | 2019-04-08 | 2019-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-08 | 2019-05-25 | N |
| Keep all essential equipment working safely. | Health | 2018-06-06 | 2018-06-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-04 | 2018-06-25 | N |
