A list of the most recent deficiencies for St. Barbara's Memorial Nursing Home. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-10-11 | 2023-11-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-11 | 2023-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-11 | 2023-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-11 | 2023-11-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-11 | 2023-11-02 | 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 | 2023-10-11 | 2023-11-02 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-01 | 2023-01-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2023-01-30 | 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 | 2022-12-01 | 2023-01-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-01 | 2023-01-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-01 | 2023-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2023-01-30 | 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 | 2022-11-29 | 2023-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-29 | 2023-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-29 | 2023-01-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-29 | 2023-01-24 | 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 | 2021-10-26 | 2021-11-06 | Y |
| 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 | 2021-08-17 | 2021-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-10-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-08-18 | 2021-09-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-18 | 2021-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-18 | 2021-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-18 | 2021-09-01 | N |
