A list of the most recent deficiencies for Martha and Mary Health Service. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-27 | 2023-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-27 | 2023-12-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-12-11 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-27 | 2023-12-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-25 | 2023-11-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-25 | 2022-12-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-25 | 2022-12-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-25 | 2022-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-25 | 2022-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-20 | 2022-12-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-20 | 2022-12-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-20 | 2022-12-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-20 | 2022-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-20 | 2022-12-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-20 | 2022-12-02 | 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 | 2022-10-20 | 2022-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-20 | 2022-12-02 | N |
| Help the resident make transportation arrangements to and from radiology services. | Health | 2022-10-20 | 2022-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-20 | 2022-12-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-20 | 2022-12-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Meet other general requirements. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-25 | 2022-11-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-09-12 | 2019-10-25 | 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 | 2019-09-12 | 2019-10-25 | 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 | 2019-09-12 | 2019-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-12 | 2019-10-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-12 | 2019-10-25 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-12 | 2019-10-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-12 | 2019-10-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-12 | 2019-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-12 | 2019-10-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-12 | 2019-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-12 | 2019-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-12 | 2019-10-25 | 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 | 2019-09-12 | 2019-10-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-12 | 2019-10-25 | N |
| Post nurse staffing information every day. | Health | 2019-09-12 | 2019-10-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-12 | 2019-10-25 | 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 | 2019-09-12 | 2019-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-12 | 2019-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
