Deficiency Records for Mission Point Nursing and Rehab Center of Holly
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Point Nursing and Rehab Center of Holly. 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 | 2024-01-22 | 2024-02-21 | 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 | 2024-01-23 | 2024-02-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-23 | 2024-02-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-23 | 2024-02-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-23 | 2024-02-19 | 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 | 2024-01-23 | 2024-02-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-01-23 | 2024-02-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-23 | 2024-02-19 | 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 | 2024-01-23 | 2024-02-19 | 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 | 2024-01-23 | 2024-02-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-01-23 | 2024-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-23 | 2024-02-19 | 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 | 2024-01-23 | 2024-02-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-23 | 2024-02-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Have an externally vented heating system. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-01-22 | 2024-02-19 | N |
| Keep all essential equipment working safely. | Health | 2024-01-18 | 2024-02-05 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-01-23 | 2024-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-19 | 2023-10-03 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-19 | 2023-10-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-19 | 2023-09-06 | 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 | 2023-08-02 | 2023-08-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-02 | 2023-08-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-02 | 2023-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-22 | 2023-04-28 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-09 | 2023-03-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-03-07 | 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 | 2023-02-09 | 2023-03-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-09 | 2023-03-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-09 | 2023-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-09 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-03-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-09 | 2023-03-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-09 | 2023-03-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-09 | 2023-03-07 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-09 | 2023-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-09 | 2023-03-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-09 | 2023-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-09 | 2023-03-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-01 | 2022-06-17 | Y |
| 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 | 2022-06-01 | 2022-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-02 | 2022-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-02 | 2022-02-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-02 | 2022-02-22 | 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 | 2021-10-28 | 2021-11-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-28 | 2021-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-28 | 2021-11-24 | 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 | 2021-10-28 | 2021-11-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-28 | 2021-11-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-28 | 2021-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-28 | 2021-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-28 | 2021-11-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-28 | 2021-11-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-28 | 2021-11-24 | 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 | 2021-10-28 | 2021-11-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-07 | 2021-04-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-07 | 2021-04-23 | Y |
