Deficiency Records for Nans Pointe Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Nans Pointe Rehabilitation and Nursing. 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 each resident receives an accurate assessment. | Health | 2022-07-12 | 2022-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-12 | 2022-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-12 | 2022-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-12 | 2022-12-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-12 | 2022-12-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-12 | 2022-12-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-12 | 2022-12-15 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-07-12 | 2022-12-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-03 | 2022-12-15 | 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 | 2022-11-03 | 2022-12-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-03 | 2022-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-03 | 2022-12-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-03 | 2022-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-12 | 2022-12-15 | 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 | 2022-07-12 | 2022-08-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-12 | 2022-08-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-12 | 2022-08-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-12 | 2022-08-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-12 | 2022-08-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-12 | 2022-08-19 | N |
| Dispose of garbage and refuse properly. | Health | 2022-07-12 | 2022-08-19 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-07-12 | 2022-08-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-12 | 2022-08-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-12 | 2022-08-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-12 | 2022-08-19 | N |
| Report COVID19 data to residents and families. | Health | 2022-07-12 | 2022-08-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-12 | 2022-08-19 | N |
| Keep all essential equipment working safely. | Health | 2022-07-12 | 2022-08-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-12 | 2022-08-19 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-07-12 | 2022-08-19 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-07-12 | 2022-08-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-07-12 | 2022-08-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-12 | 2022-08-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-12 | 2022-08-19 | N |
| Meet other general requirements. | Fire Safety | 2022-07-20 | 2022-08-12 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-07-20 | 2022-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-10 | 2022-03-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-10 | 2022-03-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-10 | 2022-03-25 | 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 | 2022-02-10 | 2022-03-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-10 | 2022-03-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-16 | 2021-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-16 | 2020-01-16 | Y |
| 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 | 2019-05-28 | 2019-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-28 | 2019-07-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-16 | 2019-06-20 | N |
| 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 | 2019-05-16 | 2019-06-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-16 | 2019-06-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-16 | 2019-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-16 | 2019-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-16 | 2019-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-16 | 2019-06-20 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-05-16 | 2019-06-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-05-16 | 2019-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-16 | 2019-06-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-16 | 2019-06-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-16 | 2019-06-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-16 | 2019-06-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-05-16 | 2019-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2017-08-28 | 2017-11-02 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-08-10 | 2017-09-22 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-08-10 | 2017-09-22 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-10 | 2017-09-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-08-10 | 2017-09-22 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-08-10 | 2017-09-22 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-08-10 | 2017-09-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-10 | 2017-09-22 | N |
