A list of the most recent deficiencies for Monroe County Operating Inc. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-25 | 2023-09-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-25 | 2023-09-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-01 | 2023-09-15 | 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 | 2023-06-01 | 2023-09-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-01 | 2023-09-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-01 | 2023-09-15 | 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 | 2023-06-01 | 2023-09-15 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-07-25 | 2023-09-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-25 | 2023-09-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-30 | 2023-09-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-01 | 2023-06-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-01 | 2023-06-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-06-01 | 2023-06-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-01 | 2023-06-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-01 | 2023-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-01 | 2023-06-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-01 | 2023-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-01 | 2023-06-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-01 | 2023-06-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-06 | 2021-07-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-06 | 2021-07-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-06 | 2021-07-09 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-06 | 2021-07-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-06 | 2021-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-06 | 2021-07-09 | 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 | 2021-06-06 | 2021-07-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-06 | 2021-07-09 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-06 | 2021-07-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-06 | 2021-07-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-06 | 2021-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-06 | 2021-07-09 | 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 | 2021-06-06 | 2021-07-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-06 | 2021-07-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-06 | 2021-07-09 | 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 | 2021-06-06 | 2021-07-09 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-06-06 | 2021-07-09 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-06 | 2021-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-06 | 2021-07-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-06 | 2021-07-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-03 | 2021-07-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-21 | 2019-03-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-21 | 2019-03-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-21 | 2019-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-21 | 2019-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-21 | 2019-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-21 | 2019-03-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-20 | 2019-03-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-20 | 2019-03-19 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-02-20 | 2019-03-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-20 | 2019-03-19 | N |
