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Deficiency Records for Ahmc Seton Medical Center
A list of the most recent deficiencies for Ahmc Seton Medical Center. 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 Ahmc Seton Medical Center. 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 be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-14 | 2024-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | 2024-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-14 | 2024-04-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-04-20 | N |
| Keep all essential equipment working safely. | Health | 2024-02-14 | 2024-04-20 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2024-02-14 | 2024-04-20 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-02-14 | 2024-04-20 | 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 | 2024-02-14 | 2024-03-14 | 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 | 2024-02-14 | 2024-02-27 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-07 | 2024-02-24 | 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 | 2024-02-07 | 2024-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-07 | 2024-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-14 | 2024-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-28 | 2023-03-09 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-07-27 | 2022-08-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-27 | 2022-08-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-14 | 2022-08-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-14 | 2022-08-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-15 | 2022-08-05 | N |
| Keep all essential equipment working safely. | Health | 2022-02-15 | 2022-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-15 | 2022-08-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-15 | 2022-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-15 | 2022-08-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-15 | 2022-07-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-15 | 2022-07-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-15 | 2022-07-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-15 | 2022-07-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-15 | 2022-07-15 | 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 | 2022-02-15 | 2022-07-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-15 | 2022-07-15 | 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 | 2022-02-15 | 2022-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-15 | 2022-07-15 | 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 | 2022-02-15 | 2022-07-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-15 | 2022-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-15 | 2022-07-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-15 | 2022-04-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-15 | 2022-04-15 | 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 | 2022-02-15 | 2022-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-15 | 2022-03-31 | 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 | 2022-02-15 | 2022-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-15 | 2022-03-31 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-15 | 2022-03-31 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-15 | 2022-03-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-15 | 2022-03-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-15 | 2022-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-15 | 2022-03-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-15 | 2022-03-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-01 | 2019-11-20 | 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 | 2019-11-01 | 2019-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-01 | 2019-11-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-13 | 2019-11-18 | 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 | 2019-09-13 | 2019-11-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-13 | 2019-11-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-13 | 2019-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-13 | 2019-11-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-13 | 2019-11-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-13 | 2019-11-18 | 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 | 2019-09-13 | 2019-11-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-13 | 2019-11-18 | 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 | 2019-09-13 | 2019-11-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-13 | 2019-11-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-13 | 2019-11-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-13 | 2019-11-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-13 | 2019-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-11-18 | N |
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