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Deficiency Records for Martha and Mary Health Service
View the most recent health deficiencies and inspection results for Martha and Mary Health Service. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Martha and Mary Health Service. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-13 | 2026-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-02-13 | 2026-03-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2026-02-13 | 2026-03-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2026-02-13 | 2026-03-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-02-13 | 2026-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-13 | 2026-03-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-02-13 | 2026-03-20 | 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 | 2026-02-13 | 2026-03-20 | 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 | 2026-02-13 | 2026-03-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2026-02-13 | 2026-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2026-02-13 | 2026-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-02-13 | 2026-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2026-02-13 | 2026-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2026-02-13 | 2026-03-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2026-02-13 | 2026-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-05-13 | 2025-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-14 | 2025-05-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-12-16 | 2025-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-12-16 | 2025-01-24 | 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 | 2024-12-16 | 2025-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-12-16 | 2025-01-24 | 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 | 2024-12-16 | 2025-01-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-16 | 2025-01-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-12-16 | 2025-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-16 | 2025-01-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-12-16 | 2025-01-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-12-16 | 2025-01-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-12-16 | 2025-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-12-16 | 2025-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-12-16 | 2025-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-16 | 2025-01-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-12-16 | 2024-12-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-12-16 | 2024-12-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-12-16 | 2024-12-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-12-16 | 2024-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-08 | 2024-08-16 | 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 |
| 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 |
| 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 |
| 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 |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | 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 safe and appropriate respiratory care for a resident when needed. | 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 appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| Assure that each resident?s assessment is updated at least once every 3 months. | 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 |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-27 | 2023-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-27 | 2023-11-28 | N |