A list of the most recent deficiencies for Mount St Mary. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-07 | 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 | 2023-11-07 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-07 | 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 |
| Add 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. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-02-09 | 2021-04-07 | N |
