A list of the most recent deficiencies for The Citadel at Myers Park, 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? |
|---|---|---|---|---|
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-18 | 2023-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2023-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-01 | 2023-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-12-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-25 | 2023-12-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-01 | 2023-12-29 | Y |
| 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 | 2023-04-12 | 2023-06-13 | 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 | 2023-04-12 | 2023-06-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-04-12 | 2023-06-13 | 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 | 2023-04-12 | 2023-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-12 | 2023-06-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-12 | 2023-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-12 | 2023-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-12 | 2023-06-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-12 | 2023-06-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-18 | 2023-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-16 | 2023-04-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-16 | 2023-04-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-04-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-16 | 2023-04-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-04-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-04-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-04-14 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-16 | 2023-04-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-29 | 2021-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-05-20 | N |
| Keep all essential equipment working safely. | Health | 2021-03-26 | 2021-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-26 | 2021-05-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-26 | 2021-05-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-04-21 | 2021-05-20 | Y |
| Have a combustible roofing system that meets safety standards. | Fire Safety | 2019-03-19 | 2019-06-17 | 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 | 2019-03-19 | 2019-06-17 | 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 | 2019-03-19 | 2019-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-19 | 2019-06-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-19 | 2019-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-19 | 2019-06-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-19 | 2019-06-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-21 | 2019-03-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-21 | 2019-03-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-21 | 2019-03-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-02-21 | 2019-03-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-21 | 2019-03-21 | 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 | 2019-02-21 | 2019-03-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-21 | 2019-03-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-21 | 2019-03-21 | 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 | 2019-02-21 | 2019-03-21 | N |
