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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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