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Deficiency Records for St Peters Rehab and Healthcare Center
A list of the most recent deficiencies for St Peters Rehab and Healthcare 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 Peters Rehab and Healthcare 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-18 | 2024-07-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-18 | 2024-07-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-18 | 2024-07-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-18 | 2024-07-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-18 | 2024-07-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-18 | 2024-07-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-12 | 2024-07-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-12 | 2024-07-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-12 | 2024-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-12 | 2024-07-18 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-04-12 | 2024-07-18 | 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 | 2024-04-12 | 2024-07-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-12 | 2024-07-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-12 | 2024-07-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-12 | 2024-07-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-12 | 2024-07-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-12 | 2024-05-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-04-12 | 2024-05-26 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-04-12 | 2024-05-26 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-04-12 | 2024-05-26 | 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 | 2024-04-12 | 2024-05-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-12 | 2024-05-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-12 | 2024-05-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-12 | 2024-05-26 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-12 | 2024-05-26 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-04-12 | 2024-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-05-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-12 | 2024-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-12 | 2024-05-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-04-12 | 2024-05-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-12 | 2024-05-26 | 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 | 2024-04-12 | 2024-05-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-12 | 2024-05-26 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-04-12 | 2024-05-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-12 | 2024-05-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-12 | 2024-05-26 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-12 | 2024-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-12 | 2024-05-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-15 | 2024-02-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-19 | 2024-02-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-12 | 2024-02-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-12 | 2024-02-07 | Y |
| 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. | Health | 2023-11-15 | 2023-12-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-19 | 2023-11-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-19 | 2023-11-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-11-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-19 | 2023-11-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-12 | 2023-11-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-12 | 2023-11-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-12 | 2023-11-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-12 | 2023-11-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-12 | 2023-11-28 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-12 | 2023-10-13 | Y |
| 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 | 2023-09-12 | 2023-10-13 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-01 | 2023-06-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-01 | 2023-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-01 | 2023-06-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-16 | 2023-06-28 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-16 | 2023-06-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-16 | 2023-06-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-16 | 2023-06-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-16 | 2023-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-06-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-16 | 2023-06-28 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-16 | 2023-06-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-05 | 2023-05-01 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-05 | 2023-05-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-05-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2022-12-06 | Y |
| 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 | 2022-04-13 | 2022-07-18 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-13 | 2022-07-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-07-18 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-13 | 2022-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-17 | 2022-07-18 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-06-17 | 2022-07-18 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-04-13 | 2022-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-13 | 2022-07-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-13 | 2022-07-18 | N |
| Meet other general requirements. | Fire Safety | 2022-04-13 | 2022-07-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-04-13 | 2022-06-17 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-13 | 2022-06-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-13 | 2022-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-06-17 | 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 | 2022-04-13 | 2022-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-06-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-13 | 2022-06-17 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-13 | 2022-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-13 | 2022-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-13 | 2022-06-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-04-13 | 2022-06-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-06-17 | Y |
| 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 | 2022-04-13 | 2022-06-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-13 | 2022-06-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-06-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-06-17 | Y |
| 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 | 2022-04-13 | 2022-06-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-13 | 2022-06-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-13 | 2022-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-06-17 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-13 | 2022-05-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-06 | 2019-10-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-06 | 2019-10-18 | 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 | 2019-09-06 | 2019-10-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-09-06 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-10-18 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-10-18 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
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