Deficiency Records for Grace Pointe Wellness Center
Updated as of September 01, 2021
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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-09 | 2021-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-09 | 2021-07-11 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-02-08 | 2021-03-17 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-09-15 | 2020-10-15 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2020-09-15 | 2020-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-12 | 2020-09-21 | 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 | 2019-11-06 | 2019-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-06 | 2019-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-06 | 2019-12-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-11-06 | 2019-12-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-11-08 | 2019-12-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-08 | 2019-12-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-08 | 2019-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-23 | N |
| 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 | 2019-11-08 | 2019-12-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-08 | 2019-12-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-11-08 | 2019-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-08 | 2019-12-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-08 | 2019-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-08 | 2019-12-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-08 | 2019-12-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-12 | 2019-07-15 | Y |
| 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 necessary and PRN use is limited. | 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 necessary and PRN use is limited. | 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 heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-06 | Not Fixed | N |
| 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 |
