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Deficiency Records for The Citadel Mooresville
A list of the most recent deficiencies for The Citadel Mooresville. 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 The Citadel Mooresville. 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? |
|---|---|---|---|---|
| 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 | 2024-02-28 | 2024-03-29 | 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 | 2024-02-28 | 2024-03-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-28 | 2024-03-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-28 | 2024-03-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-28 | 2024-03-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-01 | 2024-03-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-01 | 2024-03-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-01 | 2024-03-05 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-01 | 2024-03-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-01 | 2024-03-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-01 | 2024-03-05 | 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 | 2024-02-01 | 2024-03-05 | 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 | 2024-02-01 | 2024-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-01 | 2024-03-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-01 | 2024-03-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-01 | 2024-03-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-01 | 2024-03-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-01 | 2024-03-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-01 | 2024-03-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-01 | 2024-03-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-01 | 2024-03-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-01 | 2024-03-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-07 | 2023-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-02-28 | Y |
| Meet other general requirements. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-10 | 2022-11-07 | 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 | 2022-08-10 | 2022-11-07 | 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 | 2022-08-10 | 2022-11-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-10 | 2022-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-20 | 2022-09-13 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-15 | 2022-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-15 | 2022-08-12 | 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 | 2022-07-15 | 2022-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-15 | 2022-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-15 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-08-12 | N |
| Dispose of garbage and refuse properly. | Health | 2022-07-15 | 2022-08-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-15 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-12 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-07-15 | 2022-08-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-15 | 2022-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-15 | 2022-08-12 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-15 | 2022-08-12 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-15 | 2022-08-12 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-15 | 2022-08-12 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-07-15 | 2022-08-12 | 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 | 2022-07-15 | 2022-08-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-15 | 2022-08-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-15 | 2022-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-15 | 2022-08-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-15 | 2022-08-12 | Y |
| 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 | 2022-07-15 | 2022-08-12 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-15 | 2022-08-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-14 | 2022-02-14 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-14 | 2022-02-14 | Y |
| 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 | 2022-01-14 | 2022-02-14 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-14 | 2022-02-14 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-14 | 2022-02-14 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-01-14 | 2022-02-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-14 | 2022-02-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-14 | 2022-02-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-14 | 2022-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-14 | 2022-02-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-14 | 2022-02-14 | Y |
| 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 | 2022-01-14 | 2022-02-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-14 | 2022-02-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-14 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-14 | 2022-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-29 | 2022-01-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-29 | 2021-12-22 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-29 | 2021-12-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-29 | 2021-12-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-29 | 2021-12-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-15 | 2021-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-15 | 2021-06-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-15 | 2021-06-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-04-15 | 2021-06-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-15 | 2021-06-09 | 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 | 2021-04-15 | 2021-06-09 | 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 | 2021-04-15 | 2021-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-15 | 2021-06-09 | 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 | 2021-04-15 | 2021-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-06-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-05 | 2021-05-21 | N |
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