Mount Pleasant, TX

Focused Care at Mount Pleasant

1-star overall rating with 1-star inspections with abuse icon flag with $240,688 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1606 Memorial Ave, Mount Pleasant, TX

(903) 572-3618

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

122

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Focused Post Acute Care Partners

Operator or chain grouping

Approved since

1990-11-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

25 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.60

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.03

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.19

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.16

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.93

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.47

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.47

CMS adjusted total nurse staffing hours

Case-mix index

1.26

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,347

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

12.74

Composite VBP score used to determine payment impact.

Payment multiplier

0.9811

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0.57

Baseline 66.07% · Performance 61.67% · Measure score 0.57 · Achievement 0 · Improvement 0.57

Adjusted total nurse staffing

1.98

Baseline 4.10 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.42%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 50 · Observed rate 20% · Lower 95% interval 8.13%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.1	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 26 · Denominator 26
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 26
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 26 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Staff flu vaccination coverage	95%	42% 53 pts better	Numerator 76 · Denominator 80
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.8%	97.1% 2.3 pts worse	93.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 98.4% · Q3 93.8% · Q4 95.2% · 4Q avg 94.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.2%	97.9% 3.7 pts worse	95.5% 1.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.3% 1.3 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 1.6% · Q4 3.2% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.4%	2.7% 2.3 pts better	11.4% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight	5.4%	3.3% 2.1 pts worse	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.2% · Q3 4.1% · Q4 8.9% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.0%	18.9% 9.1 pts worse	19.6% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 32.7% · Q3 28.0% · Q4 20.0% · 4Q avg 28.0%
Percentage of long-stay residents who received an antipsychotic medication	19.2%	10.8% 8.4 pts worse	16.7% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 24.2% · Q3 25.0% · Q4 12.5% · 4Q avg 19.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	10.4%	15.4% 5 pts better	16.3% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.1% · Q3 14.2% · Q4 11.0% · 4Q avg 10.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.0%	16.1% 8.9 pts worse	14.9% 10.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 19.1% · Q3 26.5% · Q4 45.2% · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	0.8% 0.4 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.4%	15.0% 2.4 pts worse	19.8% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 23.4% · Q3 7.5% · Q4 6.3% · 4Q avg 17.4%
Percentage of long-stay residents with pressure ulcers	3.2%	4.2% 1 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.5% · Q3 4.0% · Q4 3.3% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	39.7%	89.7% 50 pts worse	81.7% 42 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 48.6% · Q3 29.3% · Q4 36.6% · 4Q avg 39.7%
Percentage of short-stay residents who had an outpatient emergency department visit	19.6%	12.0% 7.6 pts worse	12.0% 7.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 26.5% · Expected 15.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	5.7%	1.5% 4.2 pts worse	1.6% 4.1 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	29.4%	88.0% 58.6 pts worse	79.7% 50.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 29.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	45.3%	25.9% 19.4 pts worse	23.9% 21.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 45.3% · Observed 41.2% · Expected 21.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-02 · Fire 2025-07-02

17 health deficiencies

Top issue: Environmental (3 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 2 Health 2024-05-24 · Fire 2024-05-24

27 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2023-03-09 · Fire 2023-03-09

40 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-07-02

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-02

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-15

C · Minimal harm 2025-07-02

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

D · Potential for more than minimal harm 2024-05-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-05

C · Minimal harm 2024-05-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2023-03-09

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-03-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-04-19

C · Minimal harm 2023-03-09

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2023-03-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-04-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-13

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2026-02-02

E · Potential for more than minimal harm 2025-11-26

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-12-19

E · Potential for more than minimal harm 2025-11-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-26

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-26

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-11-27

D · Potential for more than minimal harm 2025-11-26

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-12-19

E · Potential for more than minimal harm 2025-09-08

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-10-01

F · Potential for more than minimal harm 2025-07-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-08-01

F · Potential for more than minimal harm 2025-07-02

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-07-02

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-02

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-02

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-02

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-04-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-04-22

E · Potential for more than minimal harm 2025-02-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-03-10

D · Potential for more than minimal harm 2024-12-19

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-09-27

J · Immediate jeopardy 2024-05-24

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-05-25

J · Immediate jeopardy 2024-05-24

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-05-25

E · Potential for more than minimal harm 2024-05-24

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-24

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-24

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-03-24

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-23

G · Actual harm 2024-02-14

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-03-14

E · Potential for more than minimal harm 2024-02-14

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-02-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-02-14

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-02-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-02-14

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-02-14

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2024-03-14

L · Immediate jeopardy 2023-10-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-30

D · Potential for more than minimal harm 2023-10-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-11-02

D · Potential for more than minimal harm 2023-10-09

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-11-02

D · Potential for more than minimal harm 2023-03-25

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2023-03-25

D · Potential for more than minimal harm 2023-03-25

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-03-25

D · Potential for more than minimal harm 2023-03-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-03-25

E · Potential for more than minimal harm 2023-03-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-03-09