Deficiency Records for Mcpherson Operator, LLC

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Updated as of March 01, 2024

A list of the most recent deficiencies for Mcpherson Operator, LLC. 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?
Meet other general requirements. Fire Safety 2023-09-06 2023-10-09 N
Use approved construction type or materials. Fire Safety 2023-09-06 2023-10-09 N
Provide properly protected cooking facilities. Fire Safety 2023-09-06 2023-10-09 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2023-09-06 2023-10-09 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-09-06 2023-10-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-06 2023-10-09 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-09-06 2023-10-09 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-09-06 2023-10-09 N
Have proper medical gas storage and administration areas. Fire Safety 2023-09-06 2023-10-09 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-08-07 2023-09-20 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-08-07 2023-09-20 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-07 2023-09-20 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-08-07 2023-09-20 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 2023-08-07 2023-09-20 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-07 2023-09-20 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-07 2023-09-20 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-08-07 2023-09-20 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 2023-08-07 2023-09-20 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-08-07 2023-09-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-07 2023-09-20 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2023-08-07 2023-09-20 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-08-07 2023-09-20 N
Address patient/client population and determine types of services needed. Fire Safety 2022-02-09 2022-03-16 N
Implement emergency and standby power systems. Fire Safety 2022-02-09 2022-03-16 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 2022-02-09 2022-03-16 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-02-09 2022-03-16 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 2022-02-09 2022-03-16 N
Provide properly protected cooking facilities. Fire Safety 2022-02-09 2022-03-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-02-09 2022-03-16 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-02-09 2022-03-16 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-02-09 2022-03-16 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-02-09 2022-03-16 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-02-09 2022-03-16 N
Have proper medical gas storage and administration areas. Fire Safety 2022-02-09 2022-03-16 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-22 2022-02-22 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-01-19 2022-02-21 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-01-19 2022-02-21 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-01-19 2022-02-21 Y
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 2022-01-19 2022-02-21 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-01-19 2022-02-21 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-01-19 2022-02-21 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-09 2022-02-09 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 2021-07-20 2021-08-21 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 2020-07-23 2020-08-28 N
Assist a resident in gaining access to vision and hearing services. Health 2020-07-23 2020-08-28 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 2020-07-23 2020-08-28 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2020-07-23 2020-08-28 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 2020-07-23 2020-08-28 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 2020-07-23 2020-08-28 N
Provide and implement an infection prevention and control program. Health 2020-07-23 2020-08-28 N
Establish an Emergency Preparedness Program (EP). Fire Safety 2020-01-06 2020-02-05 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2020-01-06 2020-02-05 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2020-01-06 2020-02-05 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-01-06 2020-02-05 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-01-06 2020-02-05 N
Install corridor and hallway doors that block smoke. Fire Safety 2020-01-06 2020-02-05 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2020-01-06 2020-02-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-01-06 2020-02-05 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-01-06 2020-02-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-01-06 2020-02-05 N