Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Woodward
Updated as of July 01, 2020
This is not the most recent data for Mission Point Nsg and Phy Rehab Ctr of Woodward. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-12 | 2019-10-28 | 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 | 2019-10-15 | 2019-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-15 | 2019-10-28 | Y |
| 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 | 2019-09-12 | 2019-10-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-12 | 2019-10-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-09-12 | 2019-10-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-12 | 2019-10-17 | 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 | 2019-09-12 | 2019-10-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-09-12 | 2019-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-12 | 2019-10-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-12 | 2019-10-03 | 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 | 2019-09-12 | 2019-10-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-12 | 2019-10-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-12 | 2019-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-10-03 | 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 | 2019-09-12 | 2019-10-03 | 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 | 2019-09-12 | 2019-10-03 | 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 | 2019-09-12 | 2019-10-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-12 | 2019-10-03 | 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 | 2019-09-12 | 2019-10-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-12 | 2019-10-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-06 | 2019-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-04 | 2019-07-09 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2019-04-24 | 2019-05-29 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-24 | 2019-05-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-08 | 2019-03-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-08 | 2019-03-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-23 | 2018-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-23 | 2018-12-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-10-23 | 2018-12-08 | N |
| Be properly staffed | Fire Safety | 2018-10-23 | 2018-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-23 | 2018-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-24 | 2018-11-30 | 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 | 2018-10-24 | 2018-11-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-24 | 2018-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-24 | 2018-11-30 | 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 | 2018-10-24 | 2018-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-24 | 2018-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-24 | 2018-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-24 | 2018-11-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-24 | 2018-11-30 | 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 | 2018-10-24 | 2018-11-30 | 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 | 2018-10-24 | 2018-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-24 | 2018-11-30 | N |
| Keep all essential equipment working safely. | Health | 2018-10-24 | 2018-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-23 | 2018-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-23 | 2018-11-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-23 | 2018-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-23 | 2018-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-17 | 2018-08-08 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-08-21 | 2018-05-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2017-09-12 | 2017-11-14 | 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 | 2017-09-12 | 2017-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-09-12 | 2017-11-14 | 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 | 2017-09-12 | 2017-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2017-09-12 | 2017-11-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-09-13 | 2017-10-22 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-09-13 | 2017-10-22 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-13 | 2017-10-22 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-09-13 | 2017-10-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-13 | 2017-10-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-09-13 | 2017-10-22 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-13 | 2017-10-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-13 | 2017-10-22 | N |
| Keep all essential equipment working safely. | Health | 2017-09-13 | 2017-10-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-13 | 2017-10-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-09-13 | 2017-10-22 | Y |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-09-13 | 2017-10-22 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-13 | 2017-10-22 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-13 | 2017-10-22 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-16 | 2017-06-06 | Y |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-04-26 | 2017-05-17 | Y |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-04-26 | 2017-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-26 | 2017-05-12 | Y |
