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Deficiency Records for Martinsville Health and Rehab
A list of the most recent deficiencies for Martinsville Health 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 Martinsville Health 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-05 | 2022-08-22 | 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 | 2022-07-05 | 2022-08-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-05 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-15 | 2022-07-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-15 | 2022-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-12 | N |
| Post nurse staffing information every day. | Health | 2022-06-15 | 2022-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-15 | 2022-07-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-06-15 | 2022-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-15 | 2022-07-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-15 | 2022-07-12 | Y |
| 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 | 2019-10-18 | 2020-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-18 | 2020-03-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-18 | 2020-03-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-18 | 2020-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-18 | 2020-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-18 | 2020-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-18 | 2020-02-26 | 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 | 2019-10-18 | 2020-02-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-18 | 2020-02-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-18 | 2020-01-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-18 | 2020-01-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-18 | 2020-01-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-18 | 2020-01-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-18 | 2020-01-03 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-18 | 2020-01-03 | N |
| 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 | 2019-10-18 | 2020-01-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-18 | 2020-01-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-18 | 2020-01-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-18 | 2020-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-18 | 2020-01-03 | 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 | 2019-10-18 | 2020-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-18 | 2020-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-18 | 2020-01-03 | 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 | 2019-10-18 | 2020-01-03 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-18 | 2020-01-03 | 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 | 2019-10-18 | 2020-01-03 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-10-18 | 2020-01-03 | N |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2019-10-18 | 2020-01-03 | 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 | 2019-10-17 | 2019-12-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-10-17 | 2019-12-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-17 | 2019-12-12 | 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 | 2019-10-17 | 2019-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-17 | 2019-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-17 | 2019-12-12 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-06-04 | 2018-08-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-04 | 2018-08-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-06-04 | 2018-08-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-04 | 2018-08-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-06-04 | 2018-08-24 | 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 | 2018-06-04 | 2018-08-24 | 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 | 2018-06-04 | 2018-08-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-06-04 | 2018-08-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-04 | 2018-08-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-06-04 | 2018-08-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-04 | 2018-08-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-07-03 | 2018-08-07 | 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 | 2018-07-03 | 2018-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-03 | 2018-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-03 | 2018-08-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-03 | 2018-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-03 | 2018-08-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-04 | 2018-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-06-04 | 2018-07-26 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-06-04 | 2018-07-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-06-04 | 2018-07-26 | 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 | 2018-06-04 | 2018-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-04 | 2018-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-04 | 2018-07-26 | 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 | 2018-06-04 | 2018-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-06-04 | 2018-07-26 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-06-04 | 2018-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-04 | 2018-07-26 | 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 | 2018-06-04 | 2018-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-04 | 2018-07-26 | 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 | 2018-06-04 | 2018-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-06-04 | 2018-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-04 | 2018-07-26 | N |
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