A list of the most recent deficiencies for Medicalodges Jackson County. 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 | 2024-03-05 | 2024-03-15 | 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 | 2024-03-05 | 2024-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-05 | 2024-03-15 | 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 | 2024-03-05 | 2024-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-05 | 2024-03-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-29 | 2024-02-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-01-29 | 2024-02-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-29 | 2024-02-26 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-29 | 2024-02-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-29 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-29 | 2024-02-26 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-29 | 2024-02-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-29 | 2024-02-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-01-29 | 2024-02-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-29 | 2024-02-26 | 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 | 2024-01-29 | 2024-02-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-29 | 2024-02-26 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-01-29 | 2024-02-26 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-01-29 | 2024-02-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-01-29 | 2024-02-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-29 | 2024-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | 2024-02-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-29 | 2024-02-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-16 | 2023-10-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-17 | 2022-11-04 | 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 | 2022-10-17 | 2022-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-17 | 2022-11-04 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-09-27 | 2022-10-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-27 | 2022-10-26 | 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 | 2022-09-27 | 2022-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-27 | 2022-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-27 | 2022-10-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-27 | 2022-10-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-27 | 2022-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-27 | 2022-10-26 | 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 | 2022-08-10 | 2022-09-16 | 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 | 2022-08-10 | 2022-09-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-10 | 2022-09-16 | 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 | 2022-08-10 | 2022-09-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-10 | 2022-09-16 | 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 | 2022-08-10 | 2022-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-10 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-10 | 2022-09-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-10 | 2022-09-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-08 | 2022-05-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-09 | 2022-03-31 | Y |
| 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 | 2022-03-09 | 2022-03-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-11-26 | Y |
| 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 | 2021-10-14 | 2021-11-26 | Y |
| 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 | 2021-10-14 | 2021-11-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2021-11-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-27 | 2021-07-05 | 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 | 2021-05-27 | 2021-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-27 | 2021-07-05 | 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 | 2021-05-27 | 2021-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-27 | 2021-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-08 | 2021-05-06 | 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 | 2021-04-08 | 2021-05-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-08 | 2021-05-06 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-05-06 | 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 | 2021-04-08 | 2021-05-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-08 | 2021-05-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-08 | 2021-05-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-08 | 2021-05-06 | 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 | 2021-04-08 | 2021-05-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-08 | 2021-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-08 | 2021-05-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-08 | 2021-05-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-08 | 2021-05-06 | N |
