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Deficiency Records for Mcpherson Operator, LLC
A list of the most recent deficiencies for Mcpherson Operator, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mcpherson Operator, LLC. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Use approved construction type or materials. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-06 | 2023-10-09 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-08-07 | 2023-09-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-07 | 2023-09-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-07 | 2023-09-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-07 | 2023-09-20 | 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 | 2023-08-07 | 2023-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-07 | 2023-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-07 | 2023-09-20 | 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 | 2023-08-07 | 2023-09-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-07 | 2023-09-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-07 | 2023-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-07 | 2023-09-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-07 | 2023-09-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-07 | 2023-09-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-09 | 2022-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-02-22 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-19 | 2022-02-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-01-19 | 2022-02-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-19 | 2022-02-21 | Y |
| 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 | 2022-01-19 | 2022-02-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-19 | 2022-02-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-19 | 2022-02-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-09 | 2022-02-09 | 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 | 2020-07-23 | 2020-08-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-07-23 | 2020-08-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-07-23 | 2020-08-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-07-23 | 2020-08-28 | 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 | 2020-07-23 | 2020-08-28 | 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 | 2020-07-23 | 2020-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-07-23 | 2020-08-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
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