A list of the most recent deficiencies for Timely Mission Nursing Home. 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 and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-17 | 2023-09-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-17 | 2023-09-17 | 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 | 2023-08-17 | 2023-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-22 | 2023-09-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-08-22 | 2023-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-22 | 2023-08-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-21 | 2022-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-04-21 | 2022-05-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-14 | 2022-05-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-14 | 2022-05-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-21 | 2022-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-21 | 2022-04-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-28 | 2019-11-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-28 | 2019-11-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-28 | 2019-11-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-28 | 2019-11-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-24 | 2019-11-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-11-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-28 | 2019-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-28 | 2019-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-11-04 | N |
