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Deficiency Records for Providence Mount St Vincent
A list of the most recent deficiencies for Providence Mount St Vincent. 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 Providence Mount St Vincent. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-04 | 2024-06-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-14 | 2024-06-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2024-02-07 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-27 | 2023-12-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-27 | 2023-12-06 | 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 | 2023-10-27 | 2023-12-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-27 | 2023-12-06 | 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 | 2023-10-27 | 2023-12-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-12-06 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-27 | 2023-12-06 | 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 | 2023-10-27 | 2023-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-12-06 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-03 | 2022-07-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-06-03 | 2022-07-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-03 | 2022-07-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-03 | 2022-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-03 | 2022-07-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-03 | 2022-07-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-03 | 2022-07-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-03 | 2022-07-30 | 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 | 2022-06-03 | 2022-07-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-03 | 2022-07-30 | 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 | 2022-06-03 | 2022-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-03 | 2022-07-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-03 | 2022-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-03 | 2022-07-30 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-03 | 2022-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-19 | 2021-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-04 | 2019-12-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-11-04 | 2019-12-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-04 | 2019-12-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-04 | 2019-12-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-04 | 2019-12-19 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-04 | 2019-12-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-04 | 2019-12-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-04 | 2019-12-19 | 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 | 2019-11-04 | 2019-12-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-04 | 2019-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-04 | 2019-12-19 | 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 | 2019-11-04 | 2019-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-04 | 2019-12-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-04 | 2019-12-19 | 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 | 2019-11-04 | 2019-12-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-04 | 2019-12-19 | 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 | 2019-11-04 | 2019-12-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-04 | 2019-12-19 | 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 | 2019-11-04 | 2019-12-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-04 | 2019-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
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