Deficiency Records for Mission Point Nursing and Physical Rehab Ctr Ch
Updated as of April 01, 2024
A list of the most recent deficiencies for Mission Point Nursing and Physical Rehab Ctr Ch. 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 | 2023-08-09 | 2023-09-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-09 | 2023-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-09 | 2023-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-09-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-09 | 2023-08-09 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-04 | 2023-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-05-26 | 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 | 2023-04-28 | 2023-05-25 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-28 | 2023-05-25 | 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 | 2023-04-28 | 2023-05-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-28 | 2023-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-05-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-28 | 2023-05-24 | 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 | 2023-04-28 | 2023-05-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-28 | 2023-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-28 | 2023-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-28 | 2023-05-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-28 | 2023-05-19 | 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 | 2023-04-28 | 2023-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-05-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-28 | 2023-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-28 | 2023-05-19 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-03-22 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-09 | 2022-01-24 | 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 | 2021-12-09 | 2022-01-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-12-09 | 2022-01-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-10 | 2022-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-01-10 | 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 | 2021-12-10 | 2022-01-10 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-12-10 | 2022-01-10 | 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 | 2021-12-10 | 2022-01-10 | 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 | 2021-12-10 | 2022-01-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-10 | 2022-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-10 | 2022-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-01-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-09 | 2021-10-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-09 | 2021-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-10-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-26 | 2019-09-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-26 | 2019-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-26 | 2019-09-16 | 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 | 2019-07-26 | 2019-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-26 | 2019-09-16 | 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 | 2019-07-26 | 2019-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-26 | 2019-09-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-25 | 2019-09-13 | N |
