Deficiency Records for Majestic Care of Southport
Updated as of January 01, 2022
This is not the most recent data for Majestic Care of Southport. For the most recent information, click here.
A list of the most recent deficiencies for Majestic Care of Southport. 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 | 2021-07-27 | 2021-08-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Develop a communication plan. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-27 | 2021-08-26 | 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 | 2021-07-27 | 2021-08-26 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-27 | 2021-08-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-16 | 2021-08-15 | 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 | 2021-07-16 | 2021-08-15 | 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 | 2021-07-16 | 2021-08-15 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-16 | 2021-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-16 | 2021-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-02 | 2020-12-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-12-02 | 2020-12-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-16 | 2019-07-31 | N |
| Meet other general requirements. | Fire Safety | 2019-07-16 | 2019-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-16 | 2019-07-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-03 | 2019-06-28 | 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 | 2019-06-03 | 2019-06-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-03 | 2019-06-28 | 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 | 2019-06-03 | 2019-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-03 | 2019-06-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-03 | 2019-06-28 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-06-03 | 2019-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-03 | 2019-06-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Establish methods for sharing information. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-12 | 2018-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-14 | 2018-07-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-06-14 | 2018-07-14 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-06-14 | 2018-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-14 | 2018-07-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-06-14 | 2018-07-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-14 | 2018-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-14 | 2018-07-14 | N |
| Dispose of garbage and refuse properly. | Health | 2018-06-14 | 2018-07-14 | N |
