A list of the most recent deficiencies for Marian 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-06 | 2023-11-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-11-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-19 | 2023-11-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-19 | 2023-11-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-19 | 2023-11-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-11-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-19 | 2023-11-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-11-24 | 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 | 2023-10-19 | 2023-11-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-19 | 2023-11-24 | 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 | 2023-10-19 | 2023-11-24 | 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 | 2023-10-19 | 2023-11-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-19 | 2023-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-11-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-08 | 2023-09-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-16 | 2022-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-28 | 2022-12-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-28 | 2022-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-11-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-28 | 2022-11-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2022-11-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-28 | 2022-11-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-28 | 2022-11-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-28 | 2022-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-28 | 2022-11-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-09-25 | 2020-11-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-09-25 | 2020-11-23 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2020-09-25 | 2020-11-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-25 | 2020-11-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-24 | 2020-03-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-24 | 2020-03-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-24 | 2020-03-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-24 | 2020-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-24 | 2020-03-18 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-24 | 2020-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-24 | 2020-03-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-24 | 2020-03-18 | 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 | 2020-02-24 | 2020-03-18 | 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 | 2020-02-24 | 2020-03-18 | 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 | 2020-02-24 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-24 | 2020-03-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-24 | 2020-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-18 | N |
