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Deficiency Records for Providence Marianwood
A list of the most recent deficiencies for Providence Marianwood. 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 Providence Marianwood. 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 residents are fully informed and understand their health status, care and treatments. | Health | 2024-08-01 | 2024-09-09 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-08-01 | 2024-09-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-01 | 2024-09-09 | 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 | 2024-08-01 | 2024-09-09 | N |
| Respond appropriately to all alleged violations. | Health | 2024-08-01 | 2024-09-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-01 | 2024-09-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-08-01 | 2024-09-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-01 | 2024-09-09 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2024-08-01 | 2024-09-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-01 | 2024-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-01 | 2024-09-09 | 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 | 2024-08-01 | 2024-09-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-01 | 2024-09-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-01 | 2024-09-09 | N |
| Provide activities to meet all resident's needs. | Health | 2024-08-01 | 2024-09-09 | 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 | 2024-08-01 | 2024-09-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | 2024-09-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-08-01 | 2024-09-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-01 | 2024-09-09 | 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 | 2024-08-01 | 2024-09-09 | 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 | 2024-08-01 | 2024-09-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-08-01 | 2024-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-01 | 2024-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-09-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-08-01 | 2024-09-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Establish methods for sharing information. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-07-25 | 2024-08-29 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-04-12 | 2024-05-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-25 | 2023-06-07 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-25 | 2023-06-07 | 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 | 2023-04-25 | 2023-06-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-25 | 2023-06-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-25 | 2023-06-07 | 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 | 2023-04-25 | 2023-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-25 | 2023-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-25 | 2023-06-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-25 | 2023-06-07 | 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 | 2023-04-25 | 2023-06-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-25 | 2023-06-07 | N |
| Keep all essential equipment working safely. | Health | 2023-04-25 | 2023-06-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-21 | 2023-05-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-16 | 2021-10-20 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-16 | 2021-10-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-16 | 2021-10-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-16 | 2021-10-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-16 | 2021-10-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide appropriate foot care. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Provide or obtain dental services for each resident. | Health | 2021-09-16 | 2021-10-20 | 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 | 2021-09-16 | 2021-10-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-09-16 | 2021-10-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-16 | 2021-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-16 | 2021-10-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-16 | 2021-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-16 | 2021-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-13 | 2021-10-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-13 | 2021-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-13 | 2021-10-01 | N |
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