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Deficiency Records for St Leonard Hcc
A list of the most recent deficiencies for St Leonard Hcc. 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 Leonard Hcc. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-18 | 2024-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-18 | 2024-09-09 | 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 | 2024-07-18 | 2024-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-18 | 2024-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-18 | 2024-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-18 | 2024-09-09 | N |
| Provide or obtain dental services for each resident. | Health | 2024-07-18 | 2024-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-18 | 2024-09-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-18 | 2024-09-09 | 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 | 2024-07-18 | 2024-09-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-18 | 2024-09-09 | 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 | 2024-07-18 | 2024-09-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-18 | 2024-09-09 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-07-18 | 2024-09-09 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-07-18 | 2024-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-20 | 2024-03-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-20 | 2024-03-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-20 | 2024-03-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-16 | 2023-12-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-16 | 2023-11-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-06 | 2023-07-19 | 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 | 2023-05-01 | 2023-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-02-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-03 | 2023-02-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-03 | 2023-02-22 | Y |
| 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 | 2022-10-25 | 2022-11-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-12 | 2022-10-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-07 | 2022-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2021-11-30 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-06-10 | 2021-07-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-10 | 2021-07-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-10 | 2021-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-10 | 2021-07-09 | 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 | 2021-06-03 | 2021-07-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-31 | 2019-04-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-31 | 2019-04-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-01-30 | 2019-04-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-01-30 | 2019-04-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-30 | 2019-04-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-30 | 2019-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-30 | 2019-04-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-31 | 2019-04-02 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-31 | 2019-04-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-31 | 2019-04-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-31 | 2019-04-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-31 | 2019-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-31 | 2019-04-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-31 | 2019-04-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-01-30 | 2019-04-02 | 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 | 2019-01-30 | 2019-04-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-30 | 2019-04-02 | N |
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