St Margarets Center

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from not rated by CMS to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to not rated by CMS.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Health citation

  CMS removed citation F0758 from the health inspection on February 18, 2025.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 7, 2025.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 5, 2025.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on April 6, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on April 6, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 6, 2025.

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CMS lists this as a standard inspection.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on April 7, 2025.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on April 7, 2025.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on April 7, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on April 7, 2025.

  CMS has cited this home for K0918 2 times since 2022.

• Citation K0223. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on April 7, 2025.

• Citation K0281. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on April 7, 2025.

• Citation K0293. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on April 7, 2025.

• Citation K0311. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on April 7, 2025.

  CMS has cited this home for K0311 2 times since 2022.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on April 7, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on November 29, 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on November 21, 2023.

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CMS lists this as a standard inspection.

• Citation F0842. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on September 7, 2022.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on July 19, 2022.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 19, 2022.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 12, 2022.

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CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on July 28, 2022.

• Citation K0311. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on July 22, 2022.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on July 29, 2022.

• Citation K0531. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on July 18, 2022.

• Citation K0918. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on July 22, 2022.

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CMS lists this as a standard inspection.

• Citation F0582. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on April 3, 2020.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on April 3, 2020.

• Citation F0812. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on April 3, 2020.

• Citation F0814. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on April 3, 2020.

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