Deficiency Records for Martha and Mary Health Service
Updated as of September 01, 2021
This is not the most recent data for Martha and Mary Health Service. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-12 | 2019-10-25 | Y |
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-09-18 | 2018-11-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-09-18 | 2018-11-15 | 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 | 2018-09-18 | 2018-11-15 | 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 | 2018-09-18 | 2018-11-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-18 | 2018-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-18 | 2018-11-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-18 | 2018-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-18 | 2018-11-15 | 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 | 2018-09-18 | 2018-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-18 | 2018-11-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-09-18 | 2018-11-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-18 | 2018-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-18 | 2018-11-15 | 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 | 2018-09-18 | 2018-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-18 | 2018-11-15 | 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 | 2018-09-18 | 2018-11-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-18 | 2018-11-07 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-09-18 | 2018-10-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-18 | 2018-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-18 | 2018-10-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-18 | 2018-10-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-18 | 2018-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-18 | 2018-10-19 | 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 | 2018-09-18 | 2018-10-05 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2018-09-18 | 2018-09-18 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-08-31 | 2017-10-14 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-31 | 2017-10-14 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-31 | 2017-10-14 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-31 | 2017-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-31 | 2017-10-14 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-31 | 2017-10-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-31 | 2017-10-14 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2017-08-31 | 2017-10-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-24 | 2017-10-03 | N |
