St Edna Subacute And Rehabilitation Center
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2023 1 penalties totaling $5,000
Fine
2020 1 penalties totaling $5,330
Fine
Health Violations by Year
2025 27 violations
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.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure each resident receives an accurate assessment.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure medication error rates are not 5 percent or greater.
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.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
2024 42 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Ensure that residents are free from significant medication errors.
Provide and implement an infection prevention and control program.
Ensure that residents are fully informed and understand their health status, care and treatments.
Allow residents to self-administer drugs if determined clinically appropriate.
Reasonably accommodate the needs and preferences of each resident.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Ensure medication error rates are not 5 percent or greater.
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.
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.
2023 11 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Allow residents to self-administer drugs if determined clinically appropriate.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Report COVID19 data to residents and families.
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.
Provide and implement an infection prevention and control program.
Perform COVID19 testing on residents and staff.
2022 17 violations
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Keep all essential equipment working safely.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Allow residents to self-administer drugs if determined clinically appropriate.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2021 3 violations
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2020 2 violations
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2019 19 violations
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure medication error rates are not 5 percent or greater.
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.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Have a plan that describes the process for conducting QAPI and QAA activities.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
2018 41 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
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.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
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.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.