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Deficiency Records for Marshall Nursing and Rehabilitation Community
A list of the most recent deficiencies for Marshall Nursing and Rehabilitation Community. 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 Nursing and Rehabilitation Community. 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? |
---|---|---|---|---|
Provide properly protected cooking facilities. | Fire Safety | 2024-09-19 | 2024-12-18 | 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 | 2024-09-20 | 2024-10-17 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-20 | 2024-10-17 | N |
Ensure each resident receives an accurate assessment. | Health | 2024-09-20 | 2024-10-17 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-09-20 | 2024-10-17 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-20 | 2024-10-17 | 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 | 2024-09-20 | 2024-10-17 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-20 | 2024-10-17 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-20 | 2024-10-17 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-20 | 2024-10-17 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-09-20 | 2024-10-17 | N |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-09-20 | 2024-10-17 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-20 | 2024-10-17 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-09-20 | 2024-10-17 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-09-20 | 2024-10-17 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-09-20 | 2024-10-17 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-20 | 2024-10-17 | N |
Dispose of garbage and refuse properly. | Health | 2024-09-20 | 2024-10-17 | N |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-09-20 | 2024-10-17 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-09-20 | 2024-10-17 | N |
Have exits that are accessible at all times. | Fire Safety | 2024-09-19 | 2024-10-17 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-19 | 2024-10-17 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-19 | 2024-10-17 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-19 | 2024-10-17 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-19 | 2024-10-17 | N |
Provide and implement an infection prevention and control program. | Health | 2024-08-30 | 2024-09-16 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-24 | 2024-07-24 | Y |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | Y |
Observe each nurse aide's job performance and give regular training. | Health | 2024-05-24 | 2024-06-25 | Y |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-05-24 | 2024-06-25 | Y |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-24 | 2024-06-25 | Y |
Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-24 | 2024-06-25 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-14 | 2024-04-19 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-14 | 2024-04-19 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-14 | 2024-04-19 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-14 | 2024-04-19 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-11 | 2023-11-23 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-11 | 2023-11-23 | Y |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-11 | 2023-10-30 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-11 | 2023-10-30 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-11 | 2023-10-30 | Y |
Keep residents' personal and medical records private and confidential. | Health | 2023-08-02 | 2023-09-05 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-02 | 2023-09-05 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-02 | 2023-09-05 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-02 | 2023-09-05 | 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 | 2023-08-02 | 2023-09-05 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-02 | 2023-09-05 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-09-05 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-02 | 2023-09-05 | N |
Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-05 | Y |
Implement a program that monitors antibiotic use. | Health | 2023-08-02 | 2023-09-05 | Y |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-03 | 2023-09-05 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-03 | 2023-09-05 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-05 | 2023-05-01 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-05-01 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2023-01-24 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2023-01-09 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-30 | 2023-01-09 | Y |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-20 | 2022-08-22 | N |
Assess the resident when there is a significant change in condition | Health | 2022-07-20 | 2022-08-22 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-20 | 2022-08-22 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-20 | 2022-08-22 | N |
Ensure each resident receives an accurate assessment. | Health | 2022-07-20 | 2022-08-22 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-22 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-22 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-20 | 2022-08-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-22 | N |
Dispose of garbage and refuse properly. | Health | 2022-07-20 | 2022-08-22 | N |
Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-22 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-20 | 2022-08-22 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-20 | 2022-08-22 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-20 | 2022-08-22 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-20 | 2022-08-22 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | Y |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-20 | 2022-08-22 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-22 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-20 | 2022-08-22 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2022-07-19 | 2022-08-22 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-19 | 2022-08-22 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-04 | 2022-03-31 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-31 | Y |
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