Deficiency Records for Pemiscot County Memorial Hospital
Updated as of January 01, 2022
This is not the most recent data for Pemiscot County Memorial Hospital. For the most recent information, click here.
A list of the most recent deficiencies for Pemiscot County Memorial Hospital. 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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2021-03-11 | 2021-04-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-11 | 2021-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-11 | 2021-04-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-11 | 2021-04-15 | 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 | 2021-03-11 | 2021-04-15 | 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 | 2021-03-11 | 2021-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-11 | 2021-04-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-03-11 | 2021-04-10 | N |
| Report COVID19 data to residents and families. | Health | 2020-12-29 | 2021-02-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-03 | 2019-10-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-03 | 2019-09-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-03 | 2019-09-27 | 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 | 2019-05-10 | 2019-06-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-10 | 2019-06-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-10 | 2019-06-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-10 | 2019-06-10 | 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 | 2019-05-10 | 2019-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-10 | 2019-06-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-10 | 2019-06-10 | N |
| Post nurse staffing information every day. | Health | 2019-05-10 | 2019-06-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-05-10 | 2019-06-10 | 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 | 2019-05-10 | 2019-06-10 | 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 | 2019-05-10 | 2019-06-10 | N |
| 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 | 2019-05-10 | 2019-06-10 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-05-10 | 2019-06-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-05-10 | 2019-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-10 | 2019-06-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-10 | 2019-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-10 | 2019-06-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-10 | 2019-06-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-10 | 2019-06-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-05-10 | 2019-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-10 | 2019-06-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-10 | 2019-06-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-10 | 2019-06-10 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-06-21 | 2018-08-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-21 | 2018-08-01 | 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 | 2018-06-21 | 2018-08-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-06-21 | 2018-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-21 | 2018-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-21 | 2018-08-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-06-21 | 2018-08-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-06-21 | 2018-08-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-06-21 | 2018-08-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-06-21 | 2018-08-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-06-21 | 2018-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-21 | 2018-07-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-21 | 2018-07-13 | N |
