A list of the most recent deficiencies for Marywood Heights. 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 | 2023-06-23 | 2023-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-23 | 2023-09-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-23 | 2023-09-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-23 | 2023-09-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-23 | 2023-08-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-23 | 2023-08-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-23 | 2023-08-24 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-06-23 | 2023-08-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-23 | 2023-08-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-24 | 2023-02-28 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-01-24 | 2023-02-28 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-14 | 2022-09-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-14 | 2022-09-07 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-07-14 | 2022-09-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-14 | 2022-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-14 | 2022-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-09-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-14 | 2022-09-07 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-07-14 | 2022-09-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-14 | 2022-09-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-14 | 2022-09-07 | 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 | 2022-07-14 | 2022-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-14 | 2022-09-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-07-14 | 2022-09-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-20 | 2022-08-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-07-20 | 2022-08-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-07-20 | 2022-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-03-02 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-27 | 2021-10-14 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-07-27 | 2021-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-27 | 2021-10-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-27 | 2021-10-14 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-07-27 | 2021-10-14 | 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 | 2021-07-27 | 2021-10-14 | 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 | 2021-09-02 | 2021-10-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-02 | 2021-10-14 | N |
| 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 | 2021-09-02 | 2021-10-14 | N |
| Post nurse staffing information every day. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-02 | 2021-10-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-02 | 2021-10-14 | 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 | 2021-09-02 | 2021-10-14 | 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 | 2021-09-02 | 2021-10-14 | N |
| Provide or obtain dental services for each resident. | Health | 2021-09-02 | 2021-10-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-09-02 | 2021-10-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-09-02 | 2021-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-02 | 2021-10-14 | Y |
| 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 | 2021-09-02 | 2021-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-10-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-03 | Not Fixed | Y |
