A list of the most recent deficiencies for St Marys Home For The Aged. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-22 | 2023-07-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-22 | 2023-07-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-22 | 2023-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-22 | 2023-07-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-22 | 2023-07-22 | 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 | 2022-07-13 | 2022-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-13 | 2022-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-13 | 2022-08-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-13 | 2022-08-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-09 | 2021-07-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-09 | 2021-07-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-09 | 2021-07-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-06-09 | 2021-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-09 | 2021-07-08 | N |
