Deficiency Records for Grace Pointe Wellness Center
Updated as of June 01, 2019
This is not the most recent data for Grace Pointe Wellness Center. For the most recent information, click here.
A list of the most recent deficiencies for Grace Pointe Wellness 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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-02-12 | 2019-04-01 | 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 | 2019-02-12 | 2019-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-12 | 2019-04-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-15 | 2019-04-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-02-15 | 2019-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-15 | 2019-04-01 | 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 | 2019-02-15 | 2019-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-15 | 2019-04-01 | 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 ne | Health | 2019-02-15 | 2019-04-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-15 | 2019-04-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-15 | 2019-04-01 | 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 | 2019-02-15 | 2019-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-15 | 2019-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-15 | 2019-04-01 | 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 | 2018-10-12 | 2018-11-12 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Establish methods for sharing information. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-22 | 2018-04-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-02-22 | 2018-04-06 | 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 | 2018-02-09 | 2018-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-09 | 2018-03-23 | N |
| Provide activities to meet all resident's needs. | Health | 2018-02-09 | 2018-03-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-09 | 2018-03-23 | 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 ne | Health | 2018-02-09 | 2018-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-09 | 2018-03-23 | 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 | 2017-07-06 | 2017-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-08 | 2017-06-01 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-06 | 2017-04-28 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-04-06 | 2017-04-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-09 | 2017-02-27 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2016-12-09 | 2017-02-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-12-09 | 2017-02-27 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-09 | 2017-02-27 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-12-09 | 2017-02-27 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-09 | 2017-02-27 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-09 | 2017-02-27 | N |
| Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. | Health | 2016-12-09 | 2017-02-27 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-09 | 2017-02-27 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-12-09 | 2017-02-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-09 | 2017-02-27 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-09 | 2017-02-27 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-09 | 2017-02-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-09 | 2017-02-27 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2016-12-09 | 2017-02-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-09 | 2017-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2016-12-14 | 2016-12-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-12-14 | 2016-12-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-12-14 | 2016-12-16 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-10-20 | 2016-12-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-07-20 | 2016-08-05 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-12 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-22 | Not Fixed | N |
