Deficiency Records for Marian Regional Medical Center D/p Snf
Updated as of April 01, 2024
A list of the most recent deficiencies for Marian Regional Medical Center D/p Snf. 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2024-02-15 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-15 | 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 | 2024-02-15 | 2024-03-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-15 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-15 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-20 | 2024-03-01 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-23 | 2023-04-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-23 | 2023-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-04-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-23 | 2023-04-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-03-23 | 2023-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-04-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-23 | 2023-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-04-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-28 | 2023-04-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-28 | 2023-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-10 | 2022-01-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-10 | 2022-01-22 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-01-10 | 2022-01-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-10 | 2022-01-22 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-11 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-11 | 2019-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-11 | 2019-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-11 | 2019-06-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-06-11 | 2019-06-24 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-04-12 | 2019-05-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-12 | 2019-05-07 | 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 | 2019-04-12 | 2019-05-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-04-12 | 2019-05-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-12 | 2019-05-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-12 | 2019-05-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-12 | 2019-05-07 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-04-12 | 2019-05-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-12 | 2019-05-07 | N |
