A list of the most recent deficiencies for Marian Home. 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 a written emergency evacuation plan. | Fire Safety | 2023-03-27 | 2023-04-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-27 | 2023-04-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-27 | 2023-04-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-27 | 2023-04-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-27 | 2023-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-27 | 2023-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-27 | 2023-03-28 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-03-27 | 2023-03-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-01-24 | 2022-02-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-24 | 2022-02-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-01-24 | 2022-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-24 | 2022-02-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-24 | 2022-02-10 | 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 | 2022-01-24 | 2022-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-24 | 2022-02-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-24 | 2022-02-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-24 | 2022-02-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-24 | 2022-02-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-24 | 2022-02-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-24 | 2022-02-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-01-24 | 2022-02-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-24 | 2022-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-24 | 2022-02-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-02 | 2020-03-12 | 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 | 2020-02-20 | 2020-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-20 | 2020-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-20 | 2020-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-02 | 2020-03-06 | 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 | 2020-03-02 | 2020-03-03 | N |
