A list of the most recent deficiencies for Mary Gran Nursing Center. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-26 | 2023-07-23 | 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 | 2023-04-26 | 2023-07-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-26 | 2023-07-23 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-23 | 2023-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-04-28 | N |
| Post nurse staffing information every day. | Health | 2023-03-23 | 2023-04-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-03-23 | 2023-04-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-03-23 | 2023-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-04-28 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-03-23 | 2023-04-28 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-03-23 | 2023-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-04-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-23 | 2023-04-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-23 | 2023-04-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-23 | 2023-04-28 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-23 | 2023-04-28 | Y |
| 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 | 2023-03-23 | 2023-04-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-23 | 2023-04-28 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-23 | 2023-04-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-16 | 2022-04-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-17 | 2022-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-17 | 2022-03-14 | 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 | 2022-02-17 | 2022-03-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-17 | 2022-03-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-25 | 2020-01-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-25 | 2020-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-25 | 2020-01-09 | 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 | 2019-10-17 | 2019-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-17 | 2019-11-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-17 | 2019-11-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-17 | 2019-11-14 | 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 | 2019-10-17 | 2019-11-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-17 | 2019-11-14 | N |
