Deficiency Records for Mitchell County Hospital Health Systems Ltcu
Updated as of August 01, 2024
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Deficiency Records for Mitchell County Hospital Health Systems Ltcu
A list of the most recent deficiencies for Mitchell County Hospital Health Systems Ltcu. 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 Mitchell County Hospital Health Systems Ltcu. 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? |
|---|---|---|---|---|
| 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 | 2023-07-10 | 2023-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-31 | 2023-06-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-06-29 | 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 | 2023-05-31 | 2023-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-06-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-31 | 2023-06-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-31 | 2023-06-29 | 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 | 2023-05-31 | 2023-06-29 | 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 | 2023-05-31 | 2023-06-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-12-01 | 2021-12-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-01 | 2021-12-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-01 | 2021-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-01 | 2021-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-01 | 2021-12-22 | 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 | 2021-11-22 | 2021-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2021-12-16 | 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 | 2021-11-22 | 2021-12-16 | 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 | 2021-11-22 | 2021-12-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-03-02 | 2020-03-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-02 | 2020-03-12 | 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 | 2020-03-02 | 2020-03-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-02 | 2020-03-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Develop a communication plan. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-06 | 2020-03-06 | 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 | 2020-02-06 | 2020-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-06 | 2020-03-06 | N |
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