Deficiency Records for Mission Pines Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Mission Pines Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-13 | 2023-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-13 | 2023-11-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-13 | 2023-11-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-13 | 2023-11-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-13 | 2023-11-03 | 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 | 2023-10-13 | 2023-11-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-13 | 2023-11-03 | 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 | 2023-10-13 | 2023-11-03 | 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 | 2023-10-13 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-11-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-13 | 2023-11-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Meet other general requirements. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-12 | 2023-11-02 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-10-12 | 2023-11-02 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-12 | 2023-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-12 | 2023-10-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-12 | 2023-10-17 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-07-19 | 2023-08-04 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-06 | 2023-01-27 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-03 | 2022-12-06 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-11-08 | 2022-12-05 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-11-08 | 2022-12-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-08 | 2022-12-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-08 | 2022-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-11-08 | 2022-12-02 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-08 | 2022-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-08 | 2022-12-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Develop a communication plan. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-03 | 2022-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-07-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-17 | 2022-07-07 | 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 | 2022-06-17 | 2022-07-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-16 | 2022-04-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-06 | 2022-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-06 | 2022-02-04 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-01-06 | 2022-02-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-06 | 2022-02-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-06 | 2022-02-04 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-12-10 | 2022-02-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-10 | 2022-02-04 | Y |
| 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 | 2021-12-10 | 2022-02-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-02-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-10 | 2022-02-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-10 | 2022-02-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-10 | 2021-12-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Develop a communication plan. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish methods for sharing information. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-13 | 2020-05-15 | 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 | 2020-03-13 | 2020-05-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-03-13 | 2020-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-12 | 2020-04-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-12 | 2020-04-28 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2020-03-12 | 2020-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-12 | 2020-04-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-03-12 | 2020-04-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-12 | 2020-04-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-12 | 2020-04-28 | 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 | 2020-03-12 | 2020-04-28 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-03-12 | 2020-04-28 | 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 | 2020-03-12 | 2020-04-28 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-03-12 | 2020-04-28 | N |
