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Deficiency Records for Marin Post Acute
A list of the most recent deficiencies for Marin Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Marin Post Acute. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-27 | 2024-04-30 | 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 | 2024-02-27 | 2024-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-27 | 2024-04-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-15 | 2024-03-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-02-15 | 2024-03-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-15 | 2024-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-15 | 2024-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-20 | 2024-02-01 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-01 | 2023-07-14 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-06-01 | 2023-07-14 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-06-01 | 2023-07-14 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-12 | 2023-05-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-02 | 2023-04-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-03 | 2022-12-19 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-09-02 | 2022-10-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-02 | 2022-10-01 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-29 | 2022-08-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-01 | 2022-07-24 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-01 | 2022-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-07-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-16 | 2022-07-18 | Y |
| Keep all essential equipment working safely. | Health | 2022-05-16 | 2022-07-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-07 | 2022-03-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-07 | 2021-07-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-07 | 2021-07-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-07 | 2021-07-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-07 | 2021-07-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-07 | 2021-06-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-07 | 2021-06-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-07 | 2021-06-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-07 | 2021-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-07 | 2021-06-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-07 | 2021-06-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-07 | 2021-06-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-07 | 2021-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-06-30 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-07 | 2021-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-07 | 2021-06-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-07 | 2021-06-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-18 | 2021-06-29 | 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 | 2021-05-18 | 2021-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-18 | 2021-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-15 | 2019-10-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-15 | 2019-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-15 | 2019-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-15 | 2019-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-15 | 2019-10-15 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-07-15 | 2019-10-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-07-15 | 2019-10-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-05 | 2019-09-24 | 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 | 2019-09-05 | 2019-09-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
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