Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Ishpeming
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Ishpeming. 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? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-06 | 2024-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-11-14 | 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 | 2023-04-06 | 2023-08-03 | 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 | 2023-04-06 | 2023-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-06 | 2023-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-06 | 2023-07-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-06 | 2023-06-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-06 | 2023-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-06 | 2023-06-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-06 | 2023-06-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-05 | 2023-06-08 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-04-06 | 2023-05-06 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-04-05 | 2023-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-05 | 2023-05-05 | 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 | 2023-04-05 | 2023-05-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-05 | 2023-05-05 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-05 | 2023-05-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-05 | 2023-05-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-05 | 2023-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-05-05 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-04-05 | 2023-05-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-05 | 2023-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-05 | 2023-05-05 | Y |
| Keep all essential equipment working safely. | Health | 2023-04-05 | 2023-05-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-04-06 | 2023-05-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-18 | 2023-02-27 | 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 | 2023-01-18 | 2023-02-27 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-01-18 | 2023-02-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-01-18 | 2023-02-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-18 | 2023-02-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-18 | 2023-02-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-18 | 2023-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-02-18 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-18 | 2023-02-18 | 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 | 2023-01-18 | 2023-02-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-02-18 | Y |
| 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. | Health | 2023-01-18 | 2023-02-18 | Y |
| Post nurse staffing information every day. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-18 | 2023-02-18 | Y |
| 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 | 2023-01-18 | 2023-02-18 | Y |
| 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. | Health | 2023-01-18 | 2023-02-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-18 | 2023-02-18 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-18 | 2023-02-18 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-18 | 2023-02-18 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-01-18 | 2023-02-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-18 | 2023-02-18 | Y |
| Have a Compliance and Ethics Program. | Health | 2023-01-18 | 2023-02-18 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-01-18 | 2023-02-18 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-18 | 2023-02-18 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide training in compliance and ethics. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-01-18 | 2023-02-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-23 | 2022-06-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-25 | 2022-02-23 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | N |
| 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 | 2022-01-25 | 2022-02-23 | N |
| 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 | 2022-01-25 | 2022-02-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-01-25 | 2022-02-23 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-01-25 | 2022-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-25 | 2022-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-25 | 2022-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-25 | 2022-02-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-01-25 | 2022-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-25 | 2022-02-23 | N |
| Keep all essential equipment working safely. | Health | 2022-01-25 | 2022-02-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-25 | 2022-02-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-25 | 2022-02-23 | Y |
| 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. | Health | 2022-01-25 | 2022-02-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-12 | 2022-02-23 | 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 | 2022-01-12 | 2022-02-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-12 | 2022-02-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-12 | 2022-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-12 | 2022-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-12 | 2022-02-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-09 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-06 | 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 | 2021-08-16 | 2021-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-08 | 2021-11-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-08 | 2021-11-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-08 | 2021-11-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-08 | 2021-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-08 | 2021-11-30 | Y |
| 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. | Health | 2021-11-08 | 2021-11-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-08 | 2021-11-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-08 | 2021-11-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-08 | 2021-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-08 | 2021-11-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-08 | 2021-11-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-11-08 | 2021-11-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-08-16 | 2021-10-26 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-16 | 2021-10-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-16 | 2021-10-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-16 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-16 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-15 | 2021-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-15 | 2021-02-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-09-30 | 2020-12-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-09-30 | 2020-11-27 | 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 | 2020-09-30 | 2020-11-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-30 | 2020-11-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-15 | 2020-11-25 | 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 | 2020-09-15 | 2020-10-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-09-15 | 2020-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-15 | 2020-10-23 | 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 | 2020-09-15 | 2020-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-15 | 2020-10-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-09-15 | 2020-10-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-09-15 | 2020-10-23 | N |
| 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. | Health | 2020-09-15 | 2020-10-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-09-15 | 2020-10-23 | N |
