Deficiency Records for Marshall Nursing and Rehabilitation Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Marshall Nursing and Rehabilitation Community. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-11 | 2023-11-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-11 | 2023-11-23 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-11 | 2023-10-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-11 | 2023-10-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-11 | 2023-10-30 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-02 | 2023-09-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-02 | 2023-09-05 | 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 | 2023-08-02 | 2023-09-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-02 | 2023-09-05 | 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 | 2023-08-02 | 2023-09-05 | 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 | 2023-08-02 | 2023-09-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-09-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-02 | 2023-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-08-02 | 2023-09-05 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-03 | 2023-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-03 | 2023-09-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-05 | 2023-05-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-05-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2023-01-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2023-01-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-30 | 2023-01-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-20 | 2022-08-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-20 | 2022-08-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-20 | 2022-08-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-20 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-20 | 2022-08-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | 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 | 2022-07-20 | 2022-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-22 | N |
| Dispose of garbage and refuse properly. | Health | 2022-07-20 | 2022-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-20 | 2022-08-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-20 | 2022-08-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-20 | 2022-08-22 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-20 | 2022-08-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-08-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-20 | 2022-08-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-20 | 2022-08-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-20 | 2022-08-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-19 | 2022-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-19 | 2022-08-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-04 | 2022-03-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-31 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-04-26 | 2021-05-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-26 | 2021-05-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-26 | 2021-05-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-26 | 2021-05-25 | 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 | 2021-04-26 | 2021-05-25 | 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 | 2021-04-26 | 2021-05-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-26 | 2021-05-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-04-26 | 2021-05-25 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-26 | 2021-05-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-26 | 2021-05-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-26 | 2021-05-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-05-12 | Y |
