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Deficiency Records for Marquardt Memorial Manor
A list of the most recent deficiencies for Marquardt Memorial Manor. 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 Marquardt Memorial Manor. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-23 | 2024-03-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-21 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-21 | 2023-12-15 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-29 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-29 | 2023-07-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-28 | Y |
| 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 | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-07 | 2023-07-06 | 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 | 2022-06-07 | 2023-07-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-20 | 2022-11-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-20 | 2022-11-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-26 | 2022-08-23 | 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 | 2022-06-08 | 2022-07-07 | N |
| Provide appropriate foot care. | Health | 2022-06-08 | 2022-07-07 | 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 | 2022-06-08 | 2022-07-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-08 | 2022-07-07 | Y |
| 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 | 2022-06-07 | 2022-07-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-07 | 2022-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-21 | 2022-01-20 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-04-22 | 2021-05-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-22 | 2021-05-20 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-22 | 2021-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-22 | 2021-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-22 | 2021-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-22 | 2021-05-20 | 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 | 2021-04-22 | 2021-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-22 | 2021-05-20 | 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 | 2021-04-21 | 2021-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
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