Deficiency Records for Marlborough Hills Rehabilitation and Hlth Care Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Marlborough Hills Rehabilitation and Hlth Care Ctr. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-30 | 2024-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2024-01-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-05 | 2022-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-05 | 2022-12-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-05 | 2022-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2022-12-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-05 | 2022-12-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-05 | 2022-12-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-05 | 2022-12-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-05 | 2022-12-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-12-05 | 2022-12-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-05 | 2022-12-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-05 | 2022-12-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-23 | 2022-08-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-23 | 2022-08-09 | 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 | 2022-06-23 | 2022-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-23 | 2022-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-23 | 2022-08-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-23 | 2022-08-09 | N |
| Provide appropriate foot care. | Health | 2022-06-23 | 2022-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-23 | 2022-08-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-06-23 | 2022-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-23 | 2022-08-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-06-23 | 2022-08-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-08-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-23 | 2022-08-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 2022-05-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-24 | 2022-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-24 | 2022-05-03 | Y |
| Provide appropriate foot care. | Health | 2022-01-06 | 2022-03-14 | 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 | 2022-01-06 | 2022-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-03-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-06 | 2022-03-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-06 | 2022-02-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-06 | 2022-02-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-06 | 2022-02-16 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-06 | 2022-02-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-06 | 2022-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-06 | 2022-02-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-02-16 | 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 | 2022-01-06 | 2022-02-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-06 | 2022-02-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-06 | 2022-02-16 | 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 | 2022-01-06 | 2022-02-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-06 | 2022-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-06 | 2022-02-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-06 | 2022-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-09 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-17 | 2021-09-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-17 | 2021-09-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-17 | 2021-09-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-17 | 2021-09-17 | Y |
