Deficiency Records for Providence Little Comp of Mary Subacute Care Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Providence Little Comp of Mary Subacute 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-14 | 2024-01-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-14 | 2024-01-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-14 | 2024-01-12 | 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 | 2023-12-14 | 2024-01-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-14 | 2024-01-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-14 | 2024-01-12 | 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 | 2023-12-14 | 2024-01-12 | 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 | 2023-12-14 | 2024-01-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-01-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-01-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-12-14 | 2024-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-18 | 2024-01-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-18 | 2024-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-18 | 2024-01-10 | 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 | 2023-05-15 | 2023-06-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-03 | 2023-04-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-13 | 2023-02-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-13 | 2023-02-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-13 | 2023-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate foot care. | Health | 2023-01-13 | 2023-02-06 | 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 | 2023-01-13 | 2023-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-05 | 2019-09-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-05 | 2019-09-11 | 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 | 2019-07-05 | 2019-09-11 | 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 | 2019-07-05 | 2019-09-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-05 | 2019-09-11 | 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 | 2019-07-05 | 2019-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-05 | 2019-08-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-05 | 2019-08-16 | 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 | 2019-07-05 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-05 | 2019-08-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-05 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-05 | 2019-08-16 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2019-07-05 | 2019-08-16 | N |
