A list of the most recent deficiencies for Marymount 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-01-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2024-01-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-18 | 2024-01-16 | 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 | 2023-12-18 | 2024-01-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-18 | 2024-01-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2023-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-19 | 2023-10-20 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-30 | 2023-02-13 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-30 | 2022-11-07 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-09-30 | 2022-11-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-30 | 2022-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-30 | 2022-11-07 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-30 | 2022-11-07 | N |
| Post nurse staffing information every day. | Health | 2022-09-30 | 2022-11-07 | 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 | 2022-09-30 | 2022-11-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-30 | 2022-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-30 | 2022-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-11-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-30 | 2022-11-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-07 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-07 | 2022-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-28 | 2022-01-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-24 | 2022-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-24 | 2022-01-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-22 | 2022-01-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2022-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-22 | 2022-01-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-11-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-08 | 2021-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-08 | 2021-08-12 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-06-13 | 2019-07-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-13 | 2019-07-11 | 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 | 2019-06-13 | 2019-07-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-13 | 2019-07-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-13 | 2019-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-13 | 2019-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-14 | 2019-07-11 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-05-24 | 2018-06-26 | 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 | 2018-05-24 | 2018-06-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-05-24 | 2018-06-26 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-05-24 | 2018-06-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-24 | 2018-06-26 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-05-24 | 2018-06-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-05-24 | 2018-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-24 | 2018-06-26 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-24 | 2018-06-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-05-24 | 2018-06-26 | 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 | 2018-05-24 | 2018-06-26 | 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 | 2018-05-24 | 2018-06-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-05-24 | 2018-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-24 | 2018-06-26 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-05-24 | 2018-06-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-05-24 | 2018-06-25 | N |
