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Deficiency Records for Casa Maria Healthcare
A list of the most recent deficiencies for Casa Maria Healthcare. 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 Casa Maria Healthcare. 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 | 2024-09-20 | 2024-10-11 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-09-20 | 2024-10-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-09-20 | 2024-10-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-09-20 | 2024-10-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-20 | 2024-10-11 | N |
| Provide activities to meet all resident's needs. | Health | 2024-09-20 | 2024-10-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-20 | 2024-10-11 | N |
| Provide or obtain dental services for each resident. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-09-20 | 2024-10-11 | 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 | 2024-09-20 | 2024-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-20 | 2024-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-20 | 2024-10-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-20 | 2024-10-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-09-20 | 2024-10-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-09-11 | 2024-10-11 | N |
| 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 | 2024-09-11 | 2024-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-11 | 2024-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-11 | 2024-10-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-09-11 | 2024-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-11 | 2024-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-10 | 2024-09-11 | 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 | 2024-09-10 | 2024-09-11 | Y |
| 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 | 2024-04-25 | 2024-05-08 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-04-25 | 2024-05-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-13 | 2024-03-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-13 | 2024-03-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-13 | 2024-03-19 | 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 | 2023-12-22 | 2024-01-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-01-24 | 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 | 2023-07-07 | 2023-08-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-07 | 2023-08-07 | 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 | 2023-07-07 | 2023-08-07 | N |
| Post nurse staffing information every day. | Health | 2023-07-07 | 2023-08-07 | 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 | 2023-07-07 | 2023-08-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-07 | 2023-08-07 | N |
| Dispose of garbage and refuse properly. | Health | 2023-07-07 | 2023-08-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-07 | 2023-08-07 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-05 | 2023-08-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-05 | 2023-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-10 | 2022-09-30 | 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 | 2022-08-10 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-10 | 2022-09-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-10 | 2022-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-10 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-10 | 2022-09-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-10 | 2022-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | N |
| 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 | 2022-08-10 | 2022-09-08 | N |
| Post nurse staffing information every day. | Health | 2022-08-10 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-10 | 2022-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-10 | 2022-09-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| 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 | 2022-08-10 | 2022-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-09 | 2022-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-09 | 2022-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-09 | 2022-07-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-09 | 2022-07-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-22 | 2022-03-22 | 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 | 2022-02-22 | 2022-03-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-22 | 2022-03-22 | Y |
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