Deficiency Records for St. Mary's Hospital
Updated as of November 01, 2021
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? |
---|---|---|---|---|
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 |
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 |