Deficiency Records for Mission Point Health Campus of Jackson
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Health Campus of Jackson. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-17 | 2024-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-17 | 2024-02-12 | 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 | 2024-01-17 | 2024-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-17 | 2024-02-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-17 | 2024-02-12 | 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 | 2024-01-17 | 2024-02-12 | 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 | 2024-01-17 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-17 | 2024-02-12 | 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 | 2024-01-17 | 2024-02-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-17 | 2024-02-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-17 | 2024-02-12 | 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 | 2024-01-16 | 2024-02-12 | 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 | 2024-01-16 | 2024-02-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-02-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-16 | 2024-02-12 | 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 | 2023-12-20 | 2024-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-21 | 2023-12-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-13 | Y |
| 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 | 2023-03-30 | 2023-05-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-30 | 2023-05-05 | 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 | 2023-03-30 | 2023-05-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-30 | 2023-05-05 | 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 | 2023-03-30 | 2023-05-05 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-03-30 | 2023-05-05 | 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 | 2022-10-11 | 2022-11-08 | N |
| 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 | 2022-10-11 | 2022-11-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-11 | 2022-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-11 | 2022-11-08 | 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 | 2022-10-11 | 2022-11-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-11 | 2022-11-08 | 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 | 2022-10-11 | 2022-11-08 | 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 | 2022-10-11 | 2022-11-08 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-10-11 | 2022-11-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-11 | 2022-11-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-11 | 2022-11-08 | N |
| Meet other general requirements. | Fire Safety | 2022-10-12 | 2022-11-08 | 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 | 2022-10-12 | 2022-11-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-12 | 2022-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-12 | 2022-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-18 | 2022-09-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-18 | 2022-09-04 | Y |
| 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 | 2021-10-11 | 2021-12-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-11 | 2021-12-16 | N |
| 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 | 2021-10-11 | 2021-12-16 | 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 | 2021-10-11 | 2021-12-16 | 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 | 2021-10-11 | 2021-12-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-11 | 2021-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-11 | 2021-12-16 | N |
| 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 | 2021-10-11 | 2021-12-16 | 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 | 2021-10-11 | 2021-12-16 | 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 | 2021-10-11 | 2021-11-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-11 | 2021-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-11 | 2021-11-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-11 | 2021-11-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-11 | 2021-11-10 | 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 | 2021-10-11 | 2021-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-11 | 2021-11-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-11 | 2021-11-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-11 | 2021-11-10 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-10-11 | 2021-11-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-11 | 2021-11-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-11 | 2021-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-11 | 2021-11-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-11 | 2021-11-10 | 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 | 2021-10-11 | 2021-11-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-06 | 2021-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-06 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-06 | 2021-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-06 | 2021-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-06 | 2021-11-10 | N |
