A list of the most recent deficiencies for Focused Care at Mount Pleasant. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-10-09 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-11-10 | 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 | 2023-10-09 | 2023-11-02 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-25 | 2023-03-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-25 | 2023-03-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-25 | 2023-03-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-09 | 2023-03-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-09 | 2023-03-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-09 | 2023-03-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-09 | 2023-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-09 | 2023-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-09 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-09 | 2023-03-10 | 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 | 2023-03-09 | 2023-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-03-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-03-09 | 2023-03-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-09 | 2023-03-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-09 | 2023-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-09 | 2023-03-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-09 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-03 | 2023-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-28 | 2023-02-16 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-09 | 2022-12-12 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-12-09 | 2022-12-12 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-12-09 | 2022-12-12 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-16 | 2021-12-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-16 | 2021-12-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-16 | 2021-12-17 | 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 | 2021-08-26 | 2021-10-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-26 | 2021-08-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-22 | 2021-04-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-14 | 2020-11-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-14 | 2020-11-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-10-14 | 2020-11-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-14 | 2020-11-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-14 | 2020-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-14 | 2020-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-14 | 2020-11-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-14 | 2020-11-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-10-14 | 2020-11-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-14 | 2020-11-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-10-14 | 2020-11-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-10-14 | 2020-11-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-14 | 2020-11-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-18 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-16 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-10-14 | Not Fixed | N |
