Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Clarkston
Updated as of April 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Clarkston. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-20 | 2024-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-03 | 2024-01-13 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-01 | 2023-11-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-01 | 2023-11-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-01 | 2023-11-28 | 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 | 2023-11-01 | 2023-11-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-01 | 2023-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-01 | 2023-11-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-01 | 2023-11-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-01 | 2023-11-28 | 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 | 2023-11-01 | 2023-11-28 | 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 | 2023-11-01 | 2023-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-01 | 2023-11-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-01 | 2023-11-24 | 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 | 2023-11-01 | 2023-11-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-01 | 2023-11-24 | N |
| Honor 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. | Health | 2023-11-01 | 2023-11-24 | 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 | 2023-11-01 | 2023-11-24 | 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 | 2023-11-01 | 2023-11-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-01 | 2023-11-24 | 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 | 2023-11-01 | 2023-11-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-01 | 2023-11-24 | 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 | 2023-11-01 | 2023-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-01 | 2023-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-11-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-01 | 2023-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-11-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-17 | 2023-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-09-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-21 | 2023-08-15 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-05-23 | 2023-06-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-01 | 2023-04-19 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-01 | 2023-03-28 | 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 | 2023-03-01 | 2023-03-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-01 | 2023-03-28 | 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 | 2023-03-01 | 2023-03-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-01 | 2023-03-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-01 | 2023-03-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-01 | 2023-03-28 | 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 | 2023-03-01 | 2023-03-28 | 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 | 2023-03-01 | 2023-03-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-03-01 | 2023-03-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-05 | 2022-12-09 | 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 | 2022-10-05 | 2022-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-12-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-10-05 | 2022-12-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-05 | 2022-12-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-05 | 2022-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-05 | 2022-11-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-10-05 | 2022-11-03 | 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 | 2022-10-05 | 2022-11-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-05 | 2022-11-03 | N |
| Post nurse staffing information every day. | Health | 2022-10-05 | 2022-11-03 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-10-05 | 2022-11-03 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-10-05 | 2022-11-03 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-05 | 2022-11-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-05 | 2022-11-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-05 | 2022-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-11-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-11-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-05 | 2022-11-03 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-06 | 2022-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-06 | 2022-11-03 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-23 | 2022-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-23 | 2022-09-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-23 | 2022-09-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-16 | 2022-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-09-10 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-24 | 2021-09-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-24 | 2021-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-07-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-24 | 2021-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-24 | 2021-07-15 | N |
