A list of the most recent deficiencies for St Marys Center Inc. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-11 | 2022-10-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-11 | 2022-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-06-11 | 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 | 2022-04-11 | 2022-05-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-11 | 2022-05-13 | Y |
| 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. | Health | 2019-09-12 | 2019-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-12 | 2019-10-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-09-12 | 2019-10-31 | 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 | 2019-09-12 | 2019-10-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-12 | 2019-10-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-20 | 2018-05-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-19 | Not Fixed | Y |
