Deficiency Records for Mission Point Nsg and Phy Rehab of Superior Woods
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab of Superior Woods. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-03-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-26 | 2024-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-26 | 2024-03-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-26 | 2024-03-06 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-26 | 2024-03-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-03-06 | 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 | 2024-01-26 | 2024-03-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-26 | 2024-03-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-01-26 | 2024-03-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-25 | 2024-03-06 | 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 | 2024-01-25 | 2024-03-06 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-25 | 2024-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-02 | 2023-08-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-02 | 2023-08-15 | 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 | 2023-03-21 | 2023-04-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-21 | 2023-04-04 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-17 | 2022-12-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-17 | 2022-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-17 | 2022-12-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-17 | 2022-12-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-10-17 | 2022-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-17 | 2022-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-11-22 | 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 | 2022-10-27 | 2022-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-27 | 2022-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-11-22 | 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 | 2022-10-27 | 2022-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-27 | 2022-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-27 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-27 | 2022-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-27 | 2022-11-22 | 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 | 2022-10-27 | 2022-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-11-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-27 | 2022-11-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-27 | 2022-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-27 | 2022-11-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-11-22 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-10-17 | 2022-11-22 | 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 | 2022-10-17 | 2022-11-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-17 | 2022-11-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-17 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-07-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-28 | 2021-08-31 | 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 | 2021-07-28 | 2021-08-31 | 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 | 2021-07-28 | 2021-08-31 | N |
| Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-07-28 | 2021-08-31 | 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 | 2021-07-28 | 2021-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-28 | 2021-08-31 | 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 | 2021-07-29 | 2021-08-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-29 | 2021-08-25 | 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 | 2021-07-29 | 2021-08-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-29 | 2021-08-25 | 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 | 2021-07-29 | 2021-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-25 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-07-29 | 2021-08-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-29 | 2021-08-25 | 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 | 2021-07-29 | 2021-08-25 | 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 | 2021-07-29 | 2021-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-29 | 2021-08-25 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-29 | 2021-08-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-29 | 2021-08-25 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-29 | 2021-08-25 | 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 | 2021-07-29 | 2021-08-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-29 | 2021-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-08-25 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-06-03 | 2021-07-13 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-06-03 | 2021-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-02 | 2021-03-02 | Y |
