A list of the most recent deficiencies for Eagle Pointe Healthcare 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? |
|---|---|---|---|---|
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-26 | 2023-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-10 | Y |
| 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 | 2023-05-26 | 2023-08-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-26 | 2023-08-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-26 | 2023-08-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-26 | 2023-07-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-26 | 2023-07-26 | 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 | 2023-05-26 | 2023-07-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-26 | 2023-07-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-26 | 2023-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-26 | 2023-07-26 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-26 | 2023-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-26 | 2023-07-26 | 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 | 2023-05-26 | 2023-07-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-26 | 2023-07-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-26 | 2023-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-26 | 2023-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-26 | 2023-07-26 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-26 | 2023-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-26 | 2023-07-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-05-26 | 2023-07-26 | 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 | 2023-05-26 | 2023-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-26 | 2023-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-26 | 2023-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-26 | 2023-07-26 | N |
| Keep all essential equipment working safely. | Health | 2023-05-26 | 2023-07-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-23 | 2023-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-23 | 2022-03-23 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-02-23 | 2022-03-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-23 | 2022-03-23 | 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 | 2022-02-23 | 2022-03-23 | 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 | 2022-02-23 | 2022-03-23 | 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 | 2022-02-23 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-03-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-23 | 2022-03-23 | 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 | 2022-02-23 | 2022-03-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-22 | 2022-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-22 | 2022-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-22 | 2022-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-22 | 2022-03-14 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-02-22 | 2022-03-14 | 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 | 2019-09-25 | 2019-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-25 | 2019-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-25 | 2019-10-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-25 | 2019-10-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-25 | 2019-10-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-25 | 2019-10-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-24 | 2019-10-16 | N |
