Deficiency Records for St Edna Subacute and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for St Edna Subacute and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-05-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-21 | 2023-04-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-21 | 2023-04-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-02 | 2023-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-03-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-02 | 2023-03-02 | N |
| Report COVID19 data to residents and families. | Health | 2023-02-02 | 2023-03-02 | N |
| 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 | 2023-02-02 | 2023-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-09 | 2023-01-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-09 | 2023-01-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-18 | 2022-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-21 | 2022-10-12 | Y |
| Keep all essential equipment working safely. | Health | 2022-07-05 | 2022-07-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-24 | 2022-04-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-19 | 2022-02-09 | 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 | 2022-01-19 | 2022-02-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-19 | 2022-02-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-12 | 2022-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-12 | 2022-02-07 | 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 | 2022-01-12 | 2022-02-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-02-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-12 | 2022-02-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-12 | 2022-02-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-12 | 2022-02-07 | 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 | 2022-01-12 | 2022-02-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-01-12 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-12 | 2022-02-07 | N |
| Dispose of garbage and refuse properly. | Health | 2022-01-12 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-12 | 2022-02-07 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-07-12 | 2021-07-26 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-30 | 2021-07-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-16 | 2021-07-08 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-22 | 2019-11-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-22 | 2019-11-13 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-10-22 | 2019-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-22 | 2019-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-22 | 2019-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-22 | 2019-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-22 | 2019-11-13 | 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 | 2019-10-22 | 2019-11-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-22 | 2019-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-22 | 2019-11-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-22 | 2019-11-13 | 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 | 2019-10-22 | 2019-11-13 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-10-22 | 2019-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-22 | 2019-11-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-22 | 2019-11-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-22 | 2019-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-22 | 2019-11-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-22 | 2019-11-13 | 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 | 2019-02-27 | 2019-03-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-27 | 2019-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-17 | 2019-01-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-17 | 2019-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-17 | 2019-01-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-17 | 2019-01-07 | 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 | 2018-12-17 | 2019-01-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-17 | 2019-01-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-12-17 | 2019-01-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-17 | 2019-01-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-12-17 | 2019-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-17 | 2019-01-07 | N |
| Dispose of garbage and refuse properly. | Health | 2018-12-17 | 2019-01-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-17 | 2019-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-17 | 2019-01-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-17 | 2019-01-07 | N |
