A list of the most recent deficiencies for St. Mary's Hospital. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-26 | 2023-08-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-17 | 2022-05-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-05-18 | 2022-05-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-18 | 2022-05-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-18 | 2022-05-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-18 | 2022-05-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-24 | 2021-05-12 | 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 | 2021-02-24 | 2021-04-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-02-24 | 2021-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-24 | 2021-04-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-24 | 2021-04-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-02-24 | 2021-04-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-02-24 | 2021-04-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-02-25 | 2021-03-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-17 | 2019-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-17 | 2019-06-07 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2019-04-17 | 2019-06-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-17 | 2019-06-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-17 | 2019-05-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-17 | 2019-05-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-17 | 2019-05-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-17 | 2019-05-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-17 | 2019-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-17 | 2019-05-23 | N |
