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Deficiency Records for San Mateo Medical Center D/p Snf
A list of the most recent deficiencies for San Mateo Medical Center D/p Snf. 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 San Mateo Medical Center D/p Snf. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Develop a communication plan. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have a properly installed medical gas master alarm panel. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-21 | 2024-05-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-21 | 2024-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-21 | 2024-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-21 | 2024-04-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-21 | 2024-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-04-19 | N |
| Post nurse staffing information every day. | Health | 2024-03-21 | 2024-04-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-04-19 | 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 | 2024-03-21 | 2024-04-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-21 | 2024-04-19 | 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 | 2024-03-21 | 2024-04-19 | 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 | 2024-03-21 | 2024-04-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-21 | 2024-04-19 | 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 | 2024-03-21 | 2024-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-19 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-21 | 2024-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-19 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-03-21 | 2024-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-21 | 2024-04-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-21 | 2024-03-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-30 | 2024-03-18 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-29 | 2023-12-19 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-29 | 2023-12-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-20 | 2023-11-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-20 | 2023-11-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-20 | 2023-11-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-20 | 2023-11-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2023-11-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-20 | 2023-11-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-20 | 2023-11-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-11-17 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-10-20 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2023-11-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-26 | 2023-07-22 | 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 | 2023-05-24 | 2023-06-24 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-24 | 2023-06-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-06 | 2023-03-08 | 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 | 2023-02-06 | 2023-03-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-06 | 2023-03-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-02-06 | 2023-03-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-06 | 2023-03-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-06 | 2023-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-06 | 2023-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-30 | 2022-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-30 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-10-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-10-03 | 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 | 2022-06-30 | 2022-10-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-30 | 2022-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-10-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-12-28 | 2022-01-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-13 | 2021-06-28 | 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 | 2021-05-13 | 2021-06-28 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-13 | 2021-06-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-13 | 2021-06-28 | 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 | 2021-05-10 | 2021-06-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-10 | 2021-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-10 | 2021-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-10 | 2021-06-16 | 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 | 2021-05-10 | 2021-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-10 | 2021-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-10 | 2021-06-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-12 | 2019-10-02 | 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 | 2019-09-12 | 2019-10-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-12 | 2019-10-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-08 | 2019-09-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-08 | 2019-09-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-08 | 2019-09-30 | 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 | 2019-08-08 | 2019-09-30 | 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 | 2019-08-08 | 2019-09-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-08 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-08 | 2019-09-30 | N |
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