Deficiency Records for Eagle Pointe Skilled Nursing and Rehab
Updated as of April 01, 2024
A list of the most recent deficiencies for Eagle Pointe Skilled Nursing and Rehab. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2024-01-10 | 2024-01-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-13 | 2022-10-21 | 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 | 2022-10-13 | 2022-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-10-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-13 | 2022-10-21 | 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 | 2022-10-13 | 2022-10-21 | N |
| Use approved construction type or materials. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-11 | 2022-10-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-02 | 2021-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-02 | 2021-11-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-21 | 2019-12-16 | 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 | 2019-10-21 | 2019-12-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-21 | 2019-12-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-21 | 2019-12-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-21 | 2019-12-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-21 | 2019-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-21 | 2019-12-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-21 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-21 | 2019-12-16 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-10-21 | 2019-12-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-21 | 2019-12-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-10 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-10 | 2019-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-10 | 2019-12-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-10 | 2019-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-10 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-06 | 2018-09-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-09-04 | 2018-09-07 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-09-04 | 2018-09-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-04 | 2018-09-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-04 | 2018-09-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-04 | 2018-09-07 | N |
