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Deficiency Records for Mainplace Post Acute
A list of the most recent deficiencies for Mainplace Post Acute. 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 Mainplace Post Acute. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-08 | 2024-08-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-03 | 2024-05-24 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-05-03 | 2024-05-24 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-03-29 | 2024-04-02 | 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 | 2024-01-16 | 2024-02-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-16 | 2024-02-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-16 | 2024-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-16 | 2024-02-07 | 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 | 2023-12-20 | 2023-12-27 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-13 | 2023-10-03 | Y |
| 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 | 2023-07-20 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-19 | 2022-08-16 | 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 | 2022-03-25 | 2022-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-25 | 2022-05-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-25 | 2022-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-05-17 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-25 | 2022-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-05-17 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-25 | 2022-05-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-25 | 2022-05-17 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| 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 | 2022-02-08 | 2022-03-09 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-02-04 | 2022-02-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-28 | 2022-01-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-28 | 2022-01-04 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-11-09 | 2021-12-18 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-13 | 2019-06-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-13 | 2019-06-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-13 | 2019-06-03 | 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 | 2019-05-13 | 2019-06-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-13 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-13 | 2019-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-13 | 2019-06-03 | 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 | 2019-05-13 | 2019-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-13 | 2019-06-03 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-13 | 2019-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-13 | 2019-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-13 | 2019-06-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Develop a communication plan. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-11 | 2018-07-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-08 | 2018-06-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-08 | 2018-06-08 | 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 | 2018-05-08 | 2018-06-08 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-08 | 2018-06-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-08 | 2018-06-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-08 | 2018-06-08 | 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 | 2018-05-08 | 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 | 2018-05-08 | 2018-06-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-05-08 | 2018-06-08 | 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 | 2018-05-08 | 2018-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-08 | 2018-06-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-08 | 2018-06-08 | N |
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