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Deficiency Records for Mount St Mary
View the most recent health deficiencies and inspection results for Mount St Mary. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mount St Mary. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Establish methods for sharing information. | Fire Safety | 2025-03-31 | 2025-06-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2025-03-31 | 2025-06-06 | 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 | 2025-03-31 | 2025-04-23 | Y |
| Post nurse staffing information every day. | Health | 2025-03-31 | 2025-04-23 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-03-31 | 2025-04-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-31 | 2025-04-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-31 | 2025-04-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-03-31 | 2025-04-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-12-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-04 | 2023-12-01 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-10-04 | 2023-12-01 | 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 | 2023-10-04 | 2023-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-04 | 2023-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-11-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-04 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-04 | 2023-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-04 | 2023-11-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-04 | 2023-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-04 | 2023-11-03 | N |