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Deficiency Records for Mitchell County Hospital Health Systems Ltcu
View the most recent health deficiencies and inspection results for Mitchell County Hospital Health Systems Ltcu. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mitchell County Hospital Health Systems Ltcu. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-02-06 | 2025-04-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-02-06 | 2025-03-25 | 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 | 2025-02-06 | 2025-03-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-31 | 2023-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-31 | 2023-08-08 | 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 | 2023-05-31 | 2023-08-08 | 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 | 2023-05-31 | 2023-06-29 | 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 | 2023-05-31 | 2023-06-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-31 | 2023-06-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-31 | 2023-06-29 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-31 | 2023-06-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-06-29 | 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 | 2023-05-31 | 2023-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-06-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-11-22 | 2021-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-22 | 2021-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-22 | 2021-12-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-11-22 | 2021-12-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-22 | 2021-12-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-11-22 | 2021-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2021-12-16 | 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 | 2021-11-22 | 2021-12-16 | 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 | 2021-11-22 | 2021-12-16 | N |