Deficiency Records for Mission Point Nsg Phy Rehab Ctr of Madison Heights
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg Phy Rehab Ctr of Madison Heights. 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 | 2024-01-11 | 2024-02-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-11 | 2024-02-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-11 | 2024-02-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-11 | 2024-02-12 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-11 | 2024-02-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-11 | 2024-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-01-11 | 2024-02-12 | N |
| Post nurse staffing information every day. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-11 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-11 | 2024-02-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-11 | 2024-02-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-11 | 2024-02-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-10 | 2024-02-12 | 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 | 2024-01-10 | 2024-02-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-10 | 2024-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-10 | 2024-02-12 | 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 | 2023-04-12 | 2023-04-14 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-05-12 | 2023-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-03-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-21 | 2023-03-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-01-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-18 | 2023-01-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-01-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-20 | 2023-01-26 | 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 | 2022-12-20 | 2023-01-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-20 | 2023-01-26 | 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 | 2022-12-20 | 2023-01-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-12-20 | 2023-01-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-21 | 2023-01-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-21 | 2023-01-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-21 | 2023-01-24 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-21 | 2023-01-24 | N |
| 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. | Health | 2022-12-21 | 2023-01-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-21 | 2023-01-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-21 | 2023-01-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-21 | 2023-01-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-21 | 2023-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-21 | 2023-01-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-21 | 2023-01-24 | 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 | 2022-12-21 | 2023-01-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-21 | 2023-01-24 | N |
| Post nurse staffing information every day. | Health | 2022-12-21 | 2023-01-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-21 | 2023-01-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-21 | 2023-01-24 | 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 | 2022-12-21 | 2023-01-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-21 | 2023-01-24 | 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 | 2022-12-21 | 2023-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-21 | 2023-01-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-21 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-21 | 2023-01-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-21 | 2023-01-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-21 | 2023-01-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-21 | 2023-01-24 | 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 | 2022-12-21 | 2023-01-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-21 | 2023-01-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-21 | 2023-01-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-21 | 2023-01-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-21 | 2023-01-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-13 | 2022-11-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-13 | 2022-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-10-13 | 2022-11-04 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-10-13 | 2022-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-14 | 2022-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-14 | 2022-09-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-14 | 2022-09-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-06 | 2022-09-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-06 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-06 | 2022-09-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-06 | 2022-07-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-21 | 2022-05-12 | Y |
| 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 | 2021-08-26 | 2021-10-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-26 | 2021-10-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-08-26 | 2021-10-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-26 | 2021-10-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-26 | 2021-10-22 | 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 | 2021-08-26 | 2021-09-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-26 | 2021-09-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-26 | 2021-09-28 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-26 | 2021-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-09-28 | 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 | 2021-08-26 | 2021-09-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-26 | 2021-09-28 | 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 | 2021-08-26 | 2021-09-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-26 | 2021-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-26 | 2021-09-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-28 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-08-26 | 2021-09-28 | 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 | 2021-08-25 | 2021-09-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-25 | 2021-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-25 | 2021-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-25 | 2021-09-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-09 | 2021-04-22 | Y |
