CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Ahmc Seton Medical Center
View the most recent health deficiencies and inspection results for Ahmc Seton Medical Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Ahmc Seton Medical Center. Stay informed about quality of care issues.
| 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 | 2025-08-15 | 2026-01-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-08-15 | 2026-01-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-08-15 | 2026-01-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-08-15 | 2026-01-23 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-08-15 | 2026-01-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-08-15 | 2026-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-15 | 2026-01-23 | N |
| Respond appropriately to all alleged violations. | Health | 2025-08-15 | 2026-01-23 | 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 | 2025-08-15 | 2026-01-23 | N |
| 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 | 2025-08-15 | 2025-09-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-15 | 2025-09-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2025-08-15 | 2025-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-08-15 | 2025-09-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2025-08-15 | 2025-09-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2025-08-15 | 2025-09-11 | 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 | 2025-08-15 | 2025-09-11 | N |
| Use approved construction type or materials. | Fire Safety | 2025-08-15 | 2025-09-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-15 | 2025-09-01 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-05-08 | 2025-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-16 | 2025-06-09 | 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 | 2025-04-18 | 2025-06-06 | 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 | 2024-02-14 | 2024-04-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-02-14 | 2024-04-20 | N |
| 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 | 2024-02-14 | 2024-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-14 | 2024-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | 2024-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-14 | 2024-04-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | N |
| Keep all essential equipment working safely. | Health | 2024-02-14 | 2024-04-20 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2024-02-14 | 2024-04-20 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-03-14 | 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 | 2024-02-14 | 2024-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-14 | 2024-02-24 | 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 | 2024-02-14 | 2024-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-14 | 2024-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-14 | 2024-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-15 | 2022-08-05 | N |
| Keep all essential equipment working safely. | Health | 2022-02-15 | 2022-08-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-15 | 2022-08-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-15 | 2022-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-15 | 2022-08-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-15 | 2022-07-30 | 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 | 2022-02-15 | 2022-07-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-15 | 2022-07-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-15 | 2022-07-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-15 | 2022-07-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-15 | 2022-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-15 | 2022-07-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-15 | 2022-07-15 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-15 | 2022-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-15 | 2022-07-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-15 | 2022-07-15 | 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 | 2022-02-15 | 2022-07-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-15 | 2022-04-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-15 | 2022-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-15 | 2022-03-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2022-02-15 | 2022-03-31 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-15 | 2022-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-15 | 2022-03-31 | N |
| 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 | 2022-02-15 | 2022-03-31 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-15 | 2022-03-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-15 | 2022-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-15 | 2022-03-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-15 | 2022-03-14 | N |