Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Woodward
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Woodward. 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 | 2024-01-31 | 2024-03-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-31 | 2024-03-25 | 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 | 2024-01-31 | 2024-03-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-31 | 2024-03-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-01 | 2024-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-01 | 2024-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-01 | 2024-03-10 | N |
| 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 | 2024-02-01 | 2024-03-10 | 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 | 2024-02-01 | 2024-03-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-01 | 2024-03-10 | N |
| 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 | 2024-02-01 | 2024-03-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-01 | 2024-03-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-01 | 2024-03-10 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-21 | 2023-04-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-03 | 2022-12-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-03 | 2022-12-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-03 | 2022-12-05 | N |
| 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 | 2022-11-03 | 2022-12-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-03 | 2022-12-05 | 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 | 2022-11-03 | 2022-12-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-03 | 2022-12-05 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-03 | 2022-12-02 | 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 | 2022-11-03 | 2022-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-06-10 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-09-02 | 2021-12-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-02 | 2021-11-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-02 | 2021-11-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-02 | 2021-10-17 | 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 | 2021-09-02 | 2021-10-17 | 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 | 2021-09-02 | 2021-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-02 | 2021-10-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-02 | 2021-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-02 | 2021-10-11 | 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 | 2021-09-02 | 2021-10-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-02 | 2021-10-11 | 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 | 2021-09-02 | 2021-10-11 | N |
| 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 | 2021-09-02 | 2021-10-11 | N |
| Post nurse staffing information every day. | Health | 2021-09-02 | 2021-10-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-02 | 2021-10-11 | 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 | 2021-09-02 | 2021-10-11 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-09-02 | 2021-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-10-11 | N |
| Dispose of garbage and refuse properly. | Health | 2021-09-02 | 2021-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-11 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-02 | 2021-10-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-02 | 2021-10-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-02 | 2021-10-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-10-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-02 | 2021-10-11 | Y |
