A list of the most recent deficiencies for Marlora Post Acute Rehab Hosp. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-29 | 2024-02-28 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-08 | 2023-12-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-08 | 2023-12-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-08 | 2023-12-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-08 | 2023-12-31 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-08 | 2023-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-08 | 2023-12-31 | 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 | 2023-11-14 | 2023-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-11-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-19 | 2023-11-18 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-19 | 2023-11-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-25 | 2023-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-02-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-09 | 2023-01-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-09 | 2023-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-09 | 2023-01-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-09 | 2023-01-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-09 | 2023-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-09 | 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 | 2022-12-09 | 2023-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-09 | 2023-01-09 | 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 | 2022-12-09 | 2023-01-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-09 | 2023-01-09 | 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 | 2022-12-09 | 2023-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-01-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-06 | 2022-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-22 | 2022-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-09-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-14 | 2021-09-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-18 | 2021-08-30 | Y |
| 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 | 2019-07-23 | 2019-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-23 | 2019-08-22 | 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 | 2019-07-23 | 2019-08-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-23 | 2019-08-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-23 | 2019-08-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-23 | 2019-08-22 | 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 | 2019-07-23 | 2019-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-23 | 2019-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-23 | 2019-08-22 | 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 | 2019-07-20 | 2019-08-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-07-20 | 2019-08-12 | N |
