Focused Care at Mount Pleasant

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2026)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Nov 27, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

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

Potential for more than minimal harm · Environmental Deficiencies · Tag F0925 · Complaint inspection · Deficient, Provider has date of correction (Oct 1, 2025)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Aug 1, 2025)

FKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (Aug 1, 2025)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0804 · Deficient, Provider has date of correction (Aug 1, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Aug 1, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Aug 1, 2025)

DEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0726 · Deficient, Provider has date of correction (Aug 1, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Aug 1, 2025)

DHave policies on smoking.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0926 · Deficient, Provider has date of correction (Aug 1, 2025)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Apr 22, 2025)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Mar 10, 2025)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Past Non-Compliance (Sep 27, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jun 25, 2024)

EEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0802 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jun 25, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

EImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Environmental Deficiencies · Tag F0925 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0573 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

DProvide 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0699 · Deficient, Provider has date of correction (Jun 25, 2024)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Jun 25, 2024)

DEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Administration Deficiencies · Tag F0847 · Complaint inspection · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (Jun 25, 2024)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2024)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

DEmploy 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.

Potential for more than minimal harm · Administration Deficiencies · Tag F0840 · Complaint inspection · Deficient, Provider has date of correction (Mar 14, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Nov 2, 2023)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (Nov 2, 2023)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Mar 10, 2023)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0636 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (Mar 10, 2023)

EProvide 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0804 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0813 · Deficient, Provider has date of correction (Mar 10, 2023)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Deficient, Provider has date of correction (Mar 10, 2023)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Deficient, Provider has date of correction (Mar 10, 2023)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Mar 10, 2023)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Deficient, Provider has date of correction (Mar 10, 2023)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Mar 10, 2023)

DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (Mar 10, 2023)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Mar 10, 2023)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Mar 10, 2023)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (Mar 10, 2023)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Mar 10, 2023)

DEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0808 · Deficient, Provider has date of correction (Mar 10, 2023)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Deficient, Provider has date of correction (Mar 10, 2023)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Mar 10, 2023)