Deficiency Records for St. Mary's Hospital
Updated as of December 01, 2018
This is not the most recent data for St. Mary's Hospital. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-09 | 2018-07-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-09 | 2018-07-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-10 | 2018-07-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-05-10 | 2018-07-02 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-04-20 | 2017-05-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-20 | 2017-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-12 | 2017-04-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-04-12 | 2017-04-24 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-02-04 | 2016-03-23 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-02-04 | 2016-03-23 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-02-04 | 2016-03-23 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-02-04 | 2016-03-23 | N |
| A two-hour-resistant firewall separation. | Fire Safety | 2016-02-03 | Not Fixed | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-02-03 | Not Fixed | N |
