A list of the most recent deficiencies for Embassy of Marion. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-18 | 2024-01-10 | 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 | 2023-12-18 | 2024-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-10 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-24 | 2023-09-29 | 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 | 2023-08-24 | 2023-09-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-24 | 2023-09-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-24 | 2023-09-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-24 | 2023-09-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-23 | 2023-09-29 | 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 | 2023-08-23 | 2023-09-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-23 | 2023-09-29 | 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 | 2023-08-23 | 2023-09-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-23 | 2023-09-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-23 | 2023-09-29 | 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 | 2023-07-27 | 2023-08-14 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-04-27 | 2023-05-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-02-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-03 | 2023-01-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-18 | 2022-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-18 | 2022-11-01 | Y |
| Post nurse staffing information every day. | Health | 2022-10-18 | 2022-11-01 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-19 | 2022-10-07 | 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 | 2021-12-02 | 2021-12-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-24 | 2021-08-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-24 | 2021-08-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-24 | 2021-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-08-19 | 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 | 2021-06-28 | 2021-07-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-28 | 2021-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-03-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-07 | 2019-03-01 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-02-07 | 2019-03-01 | 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 | 2019-02-07 | 2019-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-06 | 2019-03-01 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-02-06 | 2019-03-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-06 | 2019-03-01 | N |
