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Deficiency Records for Peace Healthcare at Mountain City
A list of the most recent deficiencies for Peace Healthcare at Mountain City. 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 Peace Healthcare at Mountain City. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-04 | 2023-03-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-04 | 2023-03-07 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-03-07 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-09-20 | 2019-11-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-20 | 2019-11-30 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-09-20 | 2019-11-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-20 | 2019-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-11-30 | N |
| Keep all essential equipment working safely. | Health | 2019-09-20 | 2019-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-23 | 2019-11-15 | N |
| Have an externally vented heating system. | Fire Safety | 2019-09-23 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-09 | 2018-06-08 | 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 | 2018-03-09 | 2018-06-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-09 | 2018-05-18 | 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 | 2018-03-09 | 2018-05-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-09 | 2018-05-18 | 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 | 2018-03-09 | 2018-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-09 | 2018-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-09 | 2018-05-18 | 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 | 2018-03-09 | 2018-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-09 | 2018-05-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-03-09 | 2018-05-18 | N |
| Post nurse staffing information every day. | Health | 2018-03-09 | 2018-05-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-03-09 | 2018-05-18 | 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 | 2018-03-09 | 2018-05-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-09 | 2018-05-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-09 | 2018-05-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-09 | 2018-05-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-09 | 2018-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-09 | 2018-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-29 | 2018-03-28 | 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 | 2017-02-02 | 2017-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-02-02 | 2017-03-31 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2017-02-02 | 2017-03-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-02-02 | 2017-03-31 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-15 | 2017-01-29 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-12-15 | 2017-01-29 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-15 | 2017-01-29 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-15 | 2017-01-29 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-15 | 2017-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-15 | 2017-01-29 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-15 | 2017-01-29 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-15 | 2017-01-29 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-12-15 | 2017-01-29 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-15 | 2017-01-29 | N |
| Keep all essential equipment working safely. | Health | 2016-12-15 | 2017-01-29 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-15 | 2017-01-29 | N |
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