All citations for Mount St Mary

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

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Last standard health inspection on record

March 31, 2025

Showing 1 to 25 of 32 citations

No harm, with potential for more than minimal harm
Observe each nurse aide's job performance and give regular training.
Widespread (many residents). CMS level F.
Health citation F-0730, Nursing and Physician Services Deficiencies. Inspection of March 31, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 23, 2025).
No harm, with potential for more than minimal harm
Include a process for Emergency Preparedness collaboration.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0009, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Address subsistence needs for staff and patients.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Establish policies and procedures for medical documentation.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0023, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Establish methods for sharing information.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0033, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Provide a means of sharing information on occupancy/needs.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0034, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Provide family notifications of emergency plan.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0035, Emergency Preparedness Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Widespread (many residents). CMS level F.
Fire safety citation K-0211, Egress Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0346, Smoke Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0354, Smoke Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Widespread (many residents). CMS level F.
Fire safety citation K-0362, Smoke Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Widespread (many residents). CMS level F.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Widespread (many residents). CMS level F.
Fire safety citation K-0521, Services Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of March 31, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (June 6, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Widespread (many residents). CMS level F.
Health citation F-0880, Infection Control Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Widespread (many residents). CMS level F.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (December 1, 2023).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pattern (more than a few residents). CMS level E.
Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Isolated (one or a few residents). CMS level D.
Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 31, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 23, 2025).
No harm, with potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
Isolated (one or a few residents). CMS level D.
Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of March 31, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 23, 2025).
No harm, with potential for more than minimal harm
Provide safe, appropriate pain management for a resident who requires such services.
Isolated (one or a few residents). CMS level D.
Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of March 31, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 23, 2025).
No harm, with potential for more than minimal harm
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.
Isolated (one or a few residents). CMS level D.
Health citation F-0758, Pharmacy Service Deficiencies. Inspection of March 31, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 23, 2025).
No harm, with potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Isolated (one or a few residents). CMS level D.
Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Isolated (one or a few residents). CMS level D.
Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Isolated (one or a few residents). CMS level D.
Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of October 4, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (November 3, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.