A list of the most recent deficiencies for Miller's Merry 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? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-06 | 2024-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-12 | 2024-02-02 | 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 | 2024-01-12 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-12 | 2024-02-02 | 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 | 2024-01-12 | 2024-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-02-02 | 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 | 2022-12-29 | 2023-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-29 | 2023-01-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-12-29 | 2023-01-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-21 | 2022-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-21 | 2022-12-20 | 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 | 2022-11-21 | 2022-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-21 | 2022-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-21 | 2022-12-20 | 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 | 2022-11-21 | 2022-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-21 | 2022-12-20 | 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 | 2022-11-21 | 2022-12-20 | 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 | 2022-11-21 | 2022-12-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-21 | 2022-12-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-21 | 2022-12-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-21 | 2022-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-21 | 2022-12-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-09 | 2019-10-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-09 | 2019-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-09 | 2019-10-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-17 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-17 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-17 | 2019-08-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-17 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-17 | 2019-08-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-17 | 2019-08-16 | N |
