Deficiency Records for Mission Pines Nursing and Rehab Center
Updated as of August 01, 2021
This is not the most recent data for Mission Pines Nursing and Rehab Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-01-06 | 2021-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-08 | 2020-08-13 | N |
| 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 |
| 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 |
| 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 | Y |
| 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 | 2020-03-12 | 2020-04-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-14 | 2019-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-14 | 2019-12-09 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-04 | 2019-05-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-04-05 | 2019-05-03 | 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 | 2019-04-05 | 2019-05-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-05 | 2019-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-05 | 2019-05-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-05 | 2019-05-03 | 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 | 2019-04-05 | 2019-05-03 | N |
| Provide appropriate foot care. | Health | 2019-04-05 | 2019-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-05 | 2019-05-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-05 | 2019-05-03 | 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 | 2019-04-05 | 2019-05-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-05 | 2019-05-03 | 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 | 2019-04-05 | 2019-05-03 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-04-05 | 2019-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-03 | N |
| 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 | 2019-04-05 | 2019-05-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-05 | 2019-05-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-05 | 2019-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-02 | 2019-02-07 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-13 | 2018-05-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-20 | 2018-05-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-20 | 2018-05-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-20 | 2018-05-03 | 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 | 2018-03-20 | 2018-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-20 | 2018-05-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-03-20 | 2018-05-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-20 | 2018-05-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-20 | 2018-05-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-20 | 2018-05-03 | 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 | 2018-03-20 | 2018-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide activities to meet all resident's needs. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-20 | 2018-05-03 | 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 | 2018-03-20 | 2018-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-20 | 2018-05-03 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-03-20 | 2018-05-03 | 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 | 2018-03-20 | 2018-05-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-03-20 | 2018-05-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-03-20 | 2018-05-03 | 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 | 2018-03-20 | 2018-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-20 | 2018-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-20 | 2018-05-03 | N |
