CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Marymount Manor
View the most recent health deficiencies and inspection results for Marymount Manor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Marymount Manor. Stay informed about quality of care issues.
| 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 | 2025-09-09 | 2025-10-10 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-06-13 | 2025-07-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-06-13 | 2025-07-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-06-13 | 2025-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-13 | 2025-07-25 | 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 | 2025-06-13 | 2025-07-25 | N |
| Post nurse staffing information every day. | Health | 2025-06-13 | 2025-07-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-06-13 | 2025-07-25 | 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 | 2025-06-13 | 2025-07-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-06-13 | 2025-07-25 | N |
| Provide activities to meet all resident's needs. | Health | 2025-06-13 | 2025-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-06-13 | 2025-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-13 | 2025-07-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-06-13 | 2025-07-25 | 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 | 2025-06-13 | 2025-07-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-06-13 | 2025-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-06-13 | 2025-07-10 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-06-13 | 2025-07-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-25 | 2024-09-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-09-25 | 2024-09-25 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-28 | 2024-04-30 | 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 | 2024-03-28 | 2024-04-29 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-28 | 2024-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-28 | 2024-04-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-28 | 2024-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-28 | 2024-04-29 | 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 | 2024-03-28 | 2024-04-29 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-03-28 | 2024-04-29 | 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 | 2024-03-28 | 2024-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-28 | 2024-04-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-28 | 2024-04-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-28 | 2024-04-29 | Y |
| 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 | 2024-03-28 | 2024-04-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-28 | 2024-04-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-28 | 2024-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-28 | 2024-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-18 | 2024-01-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-30 | 2022-11-07 | N |
| 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 | 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 |
| Establish staff and initial training requirements. | Fire Safety | 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 |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 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 |
| 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-30 | 2022-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-28 | Not Fixed | N |