A list of the most recent deficiencies for Marjorie P Lee Retirement Community. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-17 | 2023-10-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-12-26 | 2020-02-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-26 | 2020-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-26 | 2020-02-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-26 | 2020-02-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-11 | 2018-11-30 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-10-11 | 2018-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-11 | 2018-11-30 | 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 | 2018-10-11 | 2018-11-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-11 | 2018-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-11 | 2018-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-11 | 2018-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-10 | 2018-11-30 | 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 | 2018-10-10 | 2018-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-10 | 2018-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-10 | 2018-11-30 | N |
