Deficiency Records for South Marin Health and Wellness Center
Updated as of March 01, 2024
A list of the most recent deficiencies for South Marin Health and Wellness Center. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-06-02 | 2022-07-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-17 | 2022-06-10 | 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 | 2022-05-17 | 2022-06-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-17 | 2022-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-17 | 2022-06-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-17 | 2022-06-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-17 | 2022-06-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-17 | 2022-06-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-17 | 2022-06-10 | 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 | 2022-05-17 | 2022-06-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-17 | 2022-06-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-05-17 | 2022-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-17 | 2022-06-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-12 | 2021-06-07 | 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 | 2021-05-12 | 2021-06-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-28 | 2019-08-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-28 | 2019-08-19 | 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 | 2019-05-28 | 2019-08-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-31 | 2019-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-28 | 2019-07-18 | 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 | 2019-05-28 | 2019-07-18 | 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 | 2019-05-28 | 2019-07-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-28 | 2019-07-18 | 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 | 2019-05-28 | 2019-07-18 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-05-28 | 2019-07-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-28 | 2019-07-18 | 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 | 2019-05-28 | 2019-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-28 | 2019-07-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-05-28 | 2019-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-28 | 2019-07-18 | N |
| Keep all essential equipment working safely. | Health | 2019-05-28 | 2019-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-26 | 2018-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-26 | 2018-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-26 | 2018-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-26 | 2018-08-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-31 | 2018-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-31 | 2018-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-31 | 2018-07-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-05-31 | 2018-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-31 | 2018-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-31 | 2018-07-30 | N |
