Deficiency Records for Divine Rehabilitation and Nursing at Canal Pointe
Updated as of April 01, 2024
A list of the most recent deficiencies for Divine Rehabilitation and Nursing at Canal Pointe. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-22 | 2024-03-15 | 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 | 2023-11-30 | 2024-01-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-30 | 2024-01-18 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-30 | 2024-01-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2024-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2024-01-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-30 | 2024-01-18 | 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 | 2023-11-30 | 2024-01-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-30 | 2024-01-18 | 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 | 2023-11-30 | 2024-01-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-30 | 2024-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-01-18 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-30 | 2024-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-18 | N |
| Meet other general requirements. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-30 | 2024-01-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-31 | 2023-06-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-31 | 2023-06-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-31 | 2023-06-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-31 | 2023-06-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-24 | 2022-03-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-24 | 2022-03-25 | 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 | 2022-01-24 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-17 | 2021-12-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-17 | 2021-12-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-09 | 2021-08-27 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-09 | 2021-08-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-08-09 | 2021-08-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-09 | 2021-08-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-09 | 2021-08-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-09 | 2021-08-27 | Y |
| Provide appropriate foot care. | Health | 2021-08-09 | 2021-08-27 | Y |
| 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 | 2021-08-09 | 2021-08-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-09 | 2021-08-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-09 | 2021-08-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-09 | 2021-08-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-20 | 2021-08-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-20 | 2021-08-27 | Y |
| 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 | 2021-08-02 | 2021-08-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-02 | 2021-08-27 | 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 | 2021-08-02 | 2021-08-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-02 | 2021-08-27 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-26 | 2021-08-09 | 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 | 2021-07-01 | 2021-08-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-20 | 2021-08-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-20 | 2021-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-20 | 2021-08-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-02 | 2021-04-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-16 | 2019-06-28 | 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 | 2019-05-14 | 2019-06-28 | 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 | 2019-05-14 | 2019-06-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-05-14 | 2019-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-14 | 2019-06-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-14 | 2019-06-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-14 | 2019-06-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-14 | 2019-06-28 | N |
