A list of the most recent deficiencies for Carecore at Margaret Hall. 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 and implement an infection prevention and control program. | Health | 2024-02-29 | 2024-03-20 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-23 | 2024-03-20 | 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 | 2024-01-23 | 2024-03-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-23 | 2024-03-20 | N |
| 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 | 2024-02-02 | 2024-02-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-02 | 2024-02-20 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-02 | 2024-02-20 | 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 | 2024-02-02 | 2024-02-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-02 | 2024-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-20 | 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 | 2024-02-02 | 2024-02-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-02 | 2024-02-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-02 | 2024-02-20 | Y |
| 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 | 2024-02-02 | 2024-02-20 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-12-03 | 2019-01-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-03 | 2019-01-24 | 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 | 2018-12-03 | 2019-01-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-03 | 2019-01-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-03 | 2019-01-24 | N |
