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Deficiency Records for St Anthony Health and Rehabilitation
A list of the most recent deficiencies for St Anthony Health and Rehabilitation. 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 Anthony Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-07 | 2024-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-07 | 2024-04-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-07 | 2024-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-07 | 2024-04-04 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-03-07 | 2024-04-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-07 | 2024-04-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-07 | 2024-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-04-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-07 | 2024-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-07 | 2024-04-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-04-04 | Y |
| 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. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-07 | 2024-04-04 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-03-07 | 2024-04-04 | 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 | 2023-01-20 | 2023-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-02-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-19 | 2023-02-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-13 | 2023-02-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-07-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-07 | 2022-06-22 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-24 | 2021-06-29 | 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 | 2021-05-24 | 2021-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-05-24 | 2021-06-29 | 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 | 2021-05-24 | 2021-06-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-24 | 2021-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-24 | 2021-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-24 | 2021-06-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-24 | 2021-06-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-05-24 | 2021-06-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-19 | 2021-06-29 | N |
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