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Deficiency Records for Marshall Health Care and Rehab

A list of the most recent deficiencies for Marshall Health Care and Rehab. 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 Marshall Health Care and Rehab. 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?
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2024-06-12 2024-08-27 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-12 2024-08-27 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-06-12 2024-08-27 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 2024-06-13 2024-07-23 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2024-06-12 2024-07-19 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-06-12 2024-07-02 N
Ensure each resident receives an accurate assessment. Health 2024-06-12 2024-07-01 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2024-06-12 2024-07-01 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-06-12 2024-07-01 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-06-12 2024-07-01 N
Provide enough food/fluids to maintain a resident's health. Health 2024-06-12 2024-07-01 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-06-12 2024-07-01 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2024-06-12 2024-07-01 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-06-12 2024-07-01 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-04-23 2024-05-10 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-04-05 2023-05-08 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-04-05 2023-05-08 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2023-04-05 2023-05-05 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-04-05 2023-05-05 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-04-05 2023-05-05 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 2023-04-05 2023-05-05 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2023-04-05 2023-05-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-04-05 2023-05-05 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-04-04 2023-05-03 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-04-04 2023-05-03 N
Establish staff and initial training requirements. Fire Safety 2023-04-04 2023-05-03 N
Conduct testing and exercise requirements. Fire Safety 2023-04-04 2023-05-03 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-04-04 2023-05-03 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 2023-04-04 2023-05-03 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 2023-04-04 2023-05-03 N
Provide properly protected cooking facilities. Fire Safety 2023-04-04 2023-05-03 N
Construct fire resistant interior walls. Fire Safety 2023-04-04 2023-05-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-04-04 2023-05-03 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-04-04 2023-05-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-04-04 2023-05-03 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-04-04 2023-05-03 N
Have restrictions on the use of flammable curtains. Fire Safety 2023-04-04 2023-05-03 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-04-04 2023-05-03 N
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. Fire Safety 2023-04-04 2023-05-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-04-04 2023-05-03 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-04-04 2023-05-03 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-04-04 2023-05-03 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-11-29 2022-12-23 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-11-29 2022-12-23 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-11-29 2022-12-16 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-04-20 2022-04-20 Y
Keep residents' personal and medical records private and confidential. Health 2022-04-20 2022-04-19 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-04-20 2022-04-19 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2021-12-15 2022-01-16 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-15 2022-01-16 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-12-15 2022-01-16 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2021-12-15 2022-01-16 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2021-12-15 2022-01-16 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-12-15 2022-01-16 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-12-15 2022-01-16 N
Establish staff and initial training requirements. Fire Safety 2021-12-13 2021-12-21 N
Conduct testing and exercise requirements. Fire Safety 2021-12-13 2021-12-21 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-12-13 2021-12-21 N

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