Deficiency Records for Ssm Health St Clare Meadows Care Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Ssm Health St Clare Meadows Care Ctr. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-27 | 2023-03-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-27 | 2023-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-27 | 2023-03-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-27 | 2023-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-27 | 2023-03-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-27 | 2023-03-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-27 | 2023-03-13 | 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 | 2023-02-17 | 2023-03-07 | 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 | 2023-02-17 | 2023-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-17 | 2023-02-28 | 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 | 2023-02-17 | 2023-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-17 | 2023-02-18 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-11-04 | 2021-12-31 | 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 | 2021-11-04 | 2021-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-31 | 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 | 2021-11-03 | 2021-12-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-03 | 2021-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-03 | 2021-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-03 | 2021-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-03 | 2021-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-16 | 2021-10-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-16 | 2021-10-05 | Y |
| 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 | 2021-09-16 | 2021-10-05 | Y |
| 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 | 2019-08-28 | 2019-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-28 | 2019-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-28 | 2019-09-30 | 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 | 2019-08-28 | 2019-09-30 | 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 | 2019-08-28 | 2019-09-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-08-28 | 2019-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-28 | 2019-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-28 | 2019-09-06 | N |
