A list of the most recent deficiencies for Mulder Health Care Facility. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | 2024-03-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-22 | 2024-03-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-22 | 2024-03-21 | 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 | 2024-02-22 | 2024-03-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-22 | 2024-03-21 | 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 | 2024-02-22 | 2024-03-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-22 | 2024-03-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | 2024-03-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | 2024-03-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-17 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-12-15 | 2024-01-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-18 | 2023-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-18 | 2023-11-09 | 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 | 2023-04-10 | 2023-05-12 | Y |
| 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 | 2023-04-10 | 2023-05-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-10 | 2023-05-12 | 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 | 2023-03-14 | 2023-05-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-14 | 2023-04-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-14 | 2023-04-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-14 | 2023-04-11 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-30 | 2023-01-27 | 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 | 2022-12-30 | 2023-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-30 | 2023-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-30 | 2023-01-27 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-12-30 | 2023-01-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-30 | 2023-01-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-30 | 2023-01-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-30 | 2023-01-27 | 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 | 2022-12-30 | 2023-01-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-30 | 2023-01-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-30 | 2023-01-20 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-09-13 | 2022-10-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-13 | 2022-10-12 | 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 | 2022-09-13 | 2022-10-12 | Y |
| 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 | 2022-09-13 | 2022-10-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-13 | 2022-10-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-13 | 2022-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-12 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-13 | 2022-10-12 | Y |
| Post nurse staffing information every day. | Health | 2022-09-13 | 2022-10-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-13 | 2022-10-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-13 | 2022-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-13 | 2022-10-12 | 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 | 2022-03-09 | 2022-04-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-09 | 2022-04-01 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-16 | 2021-12-17 | 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 | 2021-09-29 | 2021-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-09-29 | 2021-10-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-29 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-29 | 2021-10-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-09-29 | 2021-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-29 | 2021-10-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-29 | 2021-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-16 | 2021-10-25 | 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 | 2021-09-16 | 2021-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-16 | 2021-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-16 | 2021-10-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-16 | 2021-10-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-16 | 2021-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-16 | 2021-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-11 | 2021-05-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-11 | 2021-05-19 | Y |
