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Deficiency Records for Immaculatemarycenter For Rehabilitation and healthcare
A list of the most recent deficiencies for Immaculatemarycenter For Rehabilitation and 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 Immaculatemarycenter For Rehabilitation and 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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-05 | 2024-07-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-06-17 | 2024-07-09 | 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 | 2024-06-17 | 2024-07-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-17 | 2024-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-17 | 2024-07-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-17 | 2024-07-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-17 | 2024-07-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-06-17 | 2024-07-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-17 | 2024-07-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-17 | 2024-07-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-17 | 2024-07-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-17 | 2024-07-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-06-17 | 2024-07-09 | 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 | 2024-05-16 | 2024-06-17 | 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 | 2024-04-18 | 2024-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-18 | 2024-06-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-18 | 2024-06-17 | 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 | 2023-09-19 | 2023-10-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-19 | 2023-10-23 | 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 | 2023-09-19 | 2023-10-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-28 | 2023-09-21 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-28 | 2023-09-21 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-28 | 2023-09-21 | 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 | 2023-08-28 | 2023-09-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-28 | 2023-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-28 | 2023-09-21 | 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 | 2023-08-28 | 2023-09-21 | 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 | 2023-08-28 | 2023-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-28 | 2023-09-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-28 | 2023-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-09-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-12 | 2023-07-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-16 | 2022-12-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2022-12-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-16 | 2022-12-20 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-31 | 2022-12-20 | 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 | 2022-10-31 | 2022-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-14 | 2022-11-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-14 | 2022-11-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-14 | 2022-11-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-14 | 2022-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-14 | 2022-11-21 | N |
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