Ignite Medical Resort St Marys LLC

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install proper backup exit lighting.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Meet other general requirements that are deficient.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Egress Deficiencies

Have exits that are accessible at all times.

Emergency Preparedness Deficiencies

Address patient/client population and determine types of services needed.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Resident Rights Deficiencies

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.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

Emergency Preparedness Deficiencies

Provide a means of sharing information on occupancy/needs.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

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.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Smoke Deficiencies

Construct fire resistant interior walls.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Quality of Life and Care Deficiencies

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.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

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.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.