Deficiency Records for Marian Regional Medical Center D/p Snf
Updated as of April 01, 2023
This is not the most recent data for Marian Regional Medical Center D/p Snf. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-12-09 | 2020-12-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-09-21 | 2020-09-30 | 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 |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-16 | 2018-05-30 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-05-16 | 2018-05-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-16 | 2018-05-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-05-16 | 2018-05-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-16 | 2018-05-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-10 | 2018-05-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-10 | 2018-05-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-04-10 | 2018-05-04 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-04-10 | 2018-05-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-10 | 2018-05-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-10 | 2018-05-04 | 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 | 2018-04-10 | 2018-05-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-10 | 2018-05-04 | 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 | 2018-04-10 | 2018-05-04 | 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 | 2018-04-10 | 2018-05-04 | 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 | 2018-04-10 | 2018-05-04 | 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 | 2018-04-10 | 2018-05-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-10 | 2018-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-10 | 2018-05-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-10 | 2018-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-10 | 2018-05-04 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-03-21 | 2017-05-24 | N |
| Provide written records when a resident is transferred or discharged. | Health | 2017-03-21 | 2017-05-24 | N |
| Tell 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 | 2017-03-21 | 2017-05-24 | 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 | 2017-03-21 | 2017-05-24 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-03-21 | 2017-05-24 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-03-21 | 2017-05-24 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-21 | 2017-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-21 | 2017-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-21 | 2017-05-24 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-03-21 | 2017-05-24 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-21 | 2017-05-24 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-21 | 2017-05-24 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-21 | 2017-05-24 | N |
| Keep all essential equipment working safely. | Health | 2017-03-21 | 2017-05-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-21 | 2017-05-24 | N |
| Use approved construction type or materials. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-03-29 | 2017-04-28 | N |
