Deficiency Records for Providence Holy Cross Med Ctr D/p Snf
Updated as of April 01, 2024
A list of the most recent deficiencies for Providence Holy Cross Med Ctr D/p Snf. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-10-15 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-03-26 | 2023-04-20 | 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 | 2023-03-26 | 2023-04-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-26 | 2023-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-26 | 2023-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-26 | 2023-04-20 | 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 | 2023-03-26 | 2023-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-26 | 2023-04-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-26 | 2023-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-26 | 2023-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-26 | 2023-04-20 | 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 | 2023-03-26 | 2023-04-20 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-03-26 | 2023-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-26 | 2023-04-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Ensure gas cylinders are properly stored. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-29 | 2023-04-17 | N |
| Keep all essential equipment working safely. | Health | 2022-12-05 | 2023-01-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-14 | 2022-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-13 | 2022-07-12 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-04-22 | 2022-06-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-20 | 2022-02-16 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-29 | 2019-07-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-29 | 2019-07-22 | 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 | 2019-04-29 | 2019-07-22 | 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 | 2019-04-29 | 2019-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-29 | 2019-07-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-04-29 | 2019-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-29 | 2019-07-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-29 | 2019-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-04-22 | 2018-05-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-04-22 | 2018-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-22 | 2018-05-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-22 | 2018-05-19 | 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 | 2018-04-22 | 2018-05-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-22 | 2018-05-19 | 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 | 2018-04-22 | 2018-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-22 | 2018-05-19 | N |
