Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Clawson
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Clawson. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-08-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-13 | 2023-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-13 | 2023-08-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-13 | 2023-08-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-13 | 2023-08-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-13 | 2023-08-11 | 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 | 2023-07-13 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-16 | 2023-04-20 | Y |
| 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 | 2023-03-16 | 2023-04-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-16 | 2023-04-13 | Y |
| 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 | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-04-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-16 | 2023-04-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-13 | Y |
| 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 | 2023-03-16 | 2023-04-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-16 | 2023-04-13 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-16 | 2023-04-13 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-03-16 | 2023-04-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-13 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-06-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-06 | 2022-06-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-03-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-25 | 2022-02-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-25 | 2022-02-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-01-25 | 2022-02-22 | Y |
| 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 | 2022-01-25 | 2022-02-22 | Y |
| 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 | 2022-01-25 | 2022-02-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-25 | 2022-02-22 | 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 | 2021-12-14 | 2022-01-21 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-14 | 2022-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide appropriate foot care. | Health | 2021-12-14 | 2022-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-14 | 2022-01-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-14 | 2022-01-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-14 | 2022-01-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | 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 | 2021-12-13 | 2022-01-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-25 | 2021-10-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-25 | 2021-10-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-25 | 2021-10-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-25 | 2021-10-01 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-06-25 | 2021-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-25 | 2021-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-25 | 2021-07-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-15 | 2020-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-15 | 2020-03-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-15 | 2020-03-22 | 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 | 2020-01-15 | 2020-02-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-15 | 2020-02-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-01-15 | 2020-02-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-15 | 2020-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-15 | 2020-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-15 | 2020-02-18 | 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 | 2020-01-15 | 2020-02-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-15 | 2020-02-18 | 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 | 2020-01-15 | 2020-02-18 | 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 | 2020-01-15 | 2020-02-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-01-15 | 2020-02-18 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2020-01-15 | 2020-02-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-15 | 2020-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-15 | 2020-02-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-16 | 2020-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-16 | 2020-02-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-16 | 2020-02-18 | N |
