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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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