Deficiency Records for Mcpherson Operator, LLC
Updated as of June 01, 2023
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? |
---|---|---|---|---|
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 | 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 |
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 | 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 | 2019-02-14 | 2019-03-15 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-14 | 2019-03-15 | N |
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 | 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 | 2019-02-14 | 2019-03-15 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-14 | 2019-03-15 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-14 | 2019-03-15 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-14 | 2019-03-15 | N |
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 | N |
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 | 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 | 2019-02-14 | 2019-03-15 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-14 | 2019-03-15 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-14 | 2019-03-15 | N |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-14 | 2019-03-15 | N |
Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-03-15 | N |
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 | N |
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 |