ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE

Nursing Home Inspector

470 MANOR AVE
DOWNINGTOWN, PA 19335
Chester County
Phone: 610-873-8490
Provider Number: 395815
Last Inspection: 06/09/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 110
Beds Available: 10
Percent Occupancy: 92%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

20

Facility
16

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

20

2017
76

2016
16

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 7/19/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 7/19/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 7/19/2017
 
Failed To: Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion, unless it is unavoidable due to resident’s clinical condition. Isolated : Minimal 3 7/19/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/19/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/19/2017
 

7/22/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 9/20/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/20/2016
 
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Isolated : Minimal 3 9/20/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 9/20/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 9/20/2016
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 9/20/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 9/20/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 9/20/2016
 
Failed To: Provide special eating equipment and utensils for each resident who needs them. Isolated : Minimal 3 9/20/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/20/2016
 
Failed To: Hire sufficient dietary support personnel. Pattern : Minimal 4 9/20/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated : Minimal 3 9/20/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 9/20/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 9/20/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/20/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 9/20/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 9/20/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 9/20/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 9/20/2016
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 9/20/2016
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 9/20/2016
 

8/28/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Tell 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. Pattern : Minimal 4 10/27/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 10/27/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/27/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 10/27/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 10/27/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

2/16/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/13/2017
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 3/13/2017
 

9/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/18/2016
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 10/18/2016
 

4/18/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 6/10/2016
 

2/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 4/4/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Actual 4 4/4/2016
 

8/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 10/16/2015
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 10/16/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 10/16/2015
 

3/10/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 unknown
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 unknown
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 110 98.33 110.03
Registered Nurses 1.11 1.16 0.94
Licensed Practical / Vocational Nurses 0.81 0.99 0.85
Certified Nursing Assistants 2.23 2.49 2.26
Total Staff Hours 4.14 4.64 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 7 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 97 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 95 95
of long-stay residents experiencing one or more falls with major injury 7 3 3
of long-stay residents who have depressive symptoms 0 2 2
of long-stay residents who lose too much weight 10 6 7
of long-stay residents who received an antianxiety or hypnotic medication 13 20 22
of long-stay residents who received an antipsychotic medication 8 16 15
of long-stay residents who self-report moderate to severe pain 5 6 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 18 16 20
of long-stay residents whose need for help with daily activities has increased 10 13 15
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 60 60 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 93 82 83
of short-stay residents who had an outpatient emergency department visit 11 10 10
of short-stay residents who made improvements in function 67 59 64
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 16 16 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 82 82
of short-stay residents who were rehospitalized after a nursing home admission 26 20 20
of short-stay residents who were successfully discharged to the community 62 63 52
of short-stay residents with pressure ulcers that are new or worsened 1 0 0