Deficiency Records for St. Mary's Hospital
Updated as of July 01, 2019
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 |