Deficiency Records for Mcpherson Operator, LLC
Updated as of November 01, 2021
This is not the most recent data for Mcpherson Operator, LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-07-23 | 2020-08-28 | 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 | 2020-07-23 | 2020-08-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-07-23 | 2020-08-28 | 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 | 2020-07-23 | 2020-08-28 | 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 | 2020-07-23 | 2020-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-23 | 2020-08-28 | Y |
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-03 | 2019-08-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-03 | 2019-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-23 | 2019-07-24 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-14 | 2019-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-14 | 2019-03-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-14 | 2019-03-15 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-14 | 2019-03-15 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-02-14 | 2019-03-15 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-14 | 2019-03-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-14 | 2019-03-15 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-14 | 2019-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-03-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-14 | 2019-03-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-02 | 2019-01-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-02 | 2019-01-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-02 | 2019-01-25 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-11-30 | 2018-12-28 | 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 | 2018-11-30 | 2018-12-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-06 | 2018-11-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-06 | 2018-11-28 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-11-02 | 2017-11-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-11-02 | 2017-11-17 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-02 | 2017-11-17 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-02 | 2017-11-17 | N |
| Provide housekeeping and maintenance services. | Health | 2017-11-02 | 2017-11-17 | N |
| Provide adequate and comfortable lighting levels in all areas. | Health | 2017-11-02 | 2017-11-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-02 | 2017-11-17 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-11-02 | 2017-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-02 | 2017-11-17 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-11-02 | 2017-11-17 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-02 | 2017-11-17 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-11-02 | 2017-11-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-02 | 2017-11-17 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-11-02 | 2017-11-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-02 | 2017-11-17 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-11-02 | 2017-11-17 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2017-11-02 | 2017-11-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-11-02 | 2017-11-17 | N |
| Use approved construction type or materials. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-05-15 | 2017-06-15 | N |
