St Mary Health Care Center

Quality of Life and Care Deficiencies

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

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Egress Deficiencies

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

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

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 an approved automatic sprinkler system.

Smoke Deficiencies

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

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Administration Deficiencies

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Administration Deficiencies

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

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

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

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Nutrition and Dietary Deficiencies

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

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

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.

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.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

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.