A list of the most recent deficiencies for San Marino Healthcare 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-01-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-08 | 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 | 2023-12-15 | 2024-01-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2024-01-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-12-15 | 2024-01-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-15 | 2024-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2024-01-08 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-18 | 2024-01-05 | 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 | 2023-12-18 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-18 | 2024-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-18 | 2024-01-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-18 | 2024-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-18 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-11 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-04-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-14 | 2022-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-04 | 2022-07-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-06 | 2022-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-04 | 2022-02-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-10 | 2022-02-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-10 | 2022-02-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-10 | 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 | 2021-12-10 | 2022-02-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-02-07 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-12-10 | 2022-02-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-10 | 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 | 2021-12-10 | 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 | 2021-12-10 | 2022-02-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-12-10 | 2022-02-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-10 | 2022-02-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-10 | 2022-02-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-28 | 2022-02-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-15 | 2022-01-28 | 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 | 2021-12-15 | 2022-01-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-15 | 2022-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-22 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-03 | 2019-10-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-08-03 | 2019-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-03 | 2019-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-03 | 2019-10-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-03 | 2019-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-10-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-18 | 2019-08-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-07-18 | 2019-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-18 | 2019-08-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-18 | 2019-08-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-07-18 | 2019-08-12 | N |
| Post nurse staffing information every day. | Health | 2019-07-18 | 2019-08-12 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-07-18 | 2019-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-18 | 2019-08-12 | 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 | 2019-07-18 | 2019-08-12 | 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 | 2019-07-18 | 2019-08-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-07-18 | 2019-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-18 | 2019-08-12 | 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 and emergencies. | Health | 2019-07-18 | 2019-08-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-18 | 2019-08-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-07-18 | 2019-08-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-18 | 2019-08-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-18 | 2019-08-12 | N |
