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Deficiency Records for St Mary Health Care Center

A list of the most recent deficiencies for St Mary Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for St Mary Health Care 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-10-17 2023-11-30 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-10-17 2023-11-30 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-10-17 2023-11-30 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-17 2023-11-30 N
Assist a resident in gaining access to vision and hearing services. Health 2023-10-17 2023-11-30 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-10-17 2023-11-30 N
Post nurse staffing information every day. Health 2023-10-17 2023-11-30 N
Provide and implement an infection prevention and control program. Health 2023-10-17 2023-11-30 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-03-03 2022-03-25 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-03-03 2022-03-25 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-03-03 2022-03-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-03-03 2022-03-25 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 2022-03-03 2022-03-25 N
Provide enough food/fluids to maintain a resident's health. Health 2022-03-03 2022-03-25 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 2022-03-03 2022-03-25 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 2022-03-03 2022-03-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-03-03 2022-03-25 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-03-03 2022-03-25 N
Provide and implement an infection prevention and control program. Health 2022-03-03 2022-03-25 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-03-03 2022-03-25 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 2022-03-03 2022-03-25 N
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. Health 2021-10-13 2021-11-04 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-08-22 2019-10-14 N

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