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COMMUNITY HOSPITAL ONAGA LTCU Inspection Report, Violations & Safety Grade (ST MARYS, Kansas)

206 GRAND AVENUE, ST MARYS, Kansas 66536

Phone: 7854372286

CMS Overall:5/5

Overview & Bed Count

Certified Beds
26
Avg Residents/Day
22.6
Ownership
Non profit - Corporation
Provider Type
Medicaid
County
Pottawatomie
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health5/5
Staffing5/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityKansas AvgDifference
RN Hours per Resident per Day0.990.73+0.26
Total Nurse Hours per Resident per Day5.774.13+1.64
CMS Staffing Rating5/53.5/5-
Nursing Staff Turnover34.1%48%-

Health Citation History

9 health citations on record

DateCategoryDescriptionSeverity
2024-10-31Resident Assessment and Care Planning DeficienciesAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D – Moderate Harm Potential
2024-10-31Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2024-10-31Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential
2023-06-19Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-06-19Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.D – Moderate Harm Potential
2023-06-19Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D – Moderate Harm Potential
2023-06-19Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2023-06-19Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential
2021-12-21Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential

Fire Safety Citation History

20 fire safety citations on record

DateCategoryDescriptionSeverity
2024-10-31Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2024-10-31Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-06-19Construction DeficienciesUse approved construction type or materials.F – Moderate Harm Potential
2023-06-19Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2023-06-19Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2023-06-19Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2023-06-19Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2021-12-21Egress DeficienciesAdd 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.F – Moderate Harm Potential
2021-12-21Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2021-12-21Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2021-12-21Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2021-12-21Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.F – Moderate Harm Potential
2021-12-21Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.F – Moderate Harm Potential
2021-12-21Gas, Vacuum, and Electrical Systems DeficienciesHave a battery powered remote alarm panel in a location accessible by operating personnel.F – Moderate Harm Potential
2021-12-21Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2021-12-21Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.E – Moderate Harm Potential
2021-12-21Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.D – Moderate Harm Potential
2021-12-21Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2021-12-21Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the installation and maintenance of medical gas and medical vacuum systems.D – Moderate Harm Potential
2021-12-21Gas, Vacuum, and Electrical Systems DeficienciesEnsure gas and vacuum systems are inspected and tested as part of a maintenance program.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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