A list of the most recent deficiencies for Marigold Rehabilitation Hcc. 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 the wrongful use of the resident's belongings or money. | Health | 2023-12-06 | 2023-12-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-06 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-11-25 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-08 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-08 | 2023-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-08 | 2023-09-29 | 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 | 2023-09-08 | 2023-09-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-08 | 2023-09-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-08 | 2023-09-27 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-08 | 2023-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-08 | 2023-09-27 | 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 | 2023-09-08 | 2023-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-08 | 2023-09-27 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-09-08 | 2023-09-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-02 | 2022-11-17 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-08-03 | 2022-08-20 | 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 | 2022-08-03 | 2022-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-03 | 2022-08-20 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-04 | 2022-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-22 | 2021-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2021-11-03 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-14 | 2021-08-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-14 | 2021-08-09 | 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 | 2021-07-14 | 2021-08-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-14 | 2021-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-14 | 2021-08-09 | 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 | 2021-07-14 | 2021-08-09 | 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 | 2021-07-14 | 2021-08-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-13 | 2021-08-09 | N |
| Establish methods for sharing information. | Fire Safety | 2021-07-13 | 2021-08-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-13 | 2021-08-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-13 | 2021-08-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-07-13 | 2021-08-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-13 | 2021-08-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-13 | 2021-08-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-13 | 2021-08-06 | 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 | 2021-07-13 | 2021-08-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-13 | 2021-08-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-29 | 2021-07-02 | Y |
