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Deficiency Records for Focused Care at Mount Pleasant
A list of the most recent deficiencies for Focused Care at Mount Pleasant. 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 Focused Care at Mount Pleasant. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-05 | 2024-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-24 | 2024-06-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-24 | 2024-06-25 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | 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 | 2024-05-24 | 2024-06-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-24 | 2024-06-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-24 | 2024-06-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-05-24 | 2024-06-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-24 | 2024-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-24 | 2024-06-25 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-05-24 | 2024-06-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-24 | 2024-06-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-24 | 2024-06-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-05-24 | 2024-06-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-24 | 2024-05-25 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-05-24 | 2024-05-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-24 | 2024-04-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-24 | 2024-04-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-14 | 2024-03-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-14 | 2024-03-14 | 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 | 2024-02-14 | 2024-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-14 | 2024-03-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-14 | 2024-03-14 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-14 | 2024-03-14 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-02-14 | 2024-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-09 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-11-02 | 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 | 2023-10-09 | 2023-11-02 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| 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 | 2023-03-25 | 2023-03-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-25 | 2023-03-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-25 | 2023-03-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-09 | 2023-03-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| 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 | 2023-03-09 | 2023-03-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-09 | 2023-03-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-09 | 2023-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-03-09 | 2023-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-03-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-03-09 | 2023-03-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-09 | 2023-03-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-09 | 2023-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-09 | 2023-03-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-09 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-03 | 2023-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-09 | 2022-12-12 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-12-09 | 2022-12-12 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-12-09 | 2022-12-12 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-16 | 2021-12-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2021-12-17 | 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 | 2021-12-16 | 2021-12-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-16 | 2021-12-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-05 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-18 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-16 | Not Fixed | N |
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