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Deficiency Records for Addison Pointe Health and Rehabilitation Center
A list of the most recent deficiencies for Addison Pointe Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Addison Pointe Health and Rehabilitation 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? |
|---|---|---|---|---|
| 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 | 2024-07-31 | 2024-08-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-31 | 2024-08-16 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2024-03-14 | 2024-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-14 | 2024-03-30 | N |
| Have an externally vented heating system. | Fire Safety | 2024-03-14 | 2024-03-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-14 | 2024-03-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-14 | 2024-03-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-23 | 2024-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-23 | 2024-03-16 | N |
| 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 | 2024-02-23 | 2024-03-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-23 | 2024-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-23 | 2024-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-18 | 2023-10-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-29 | 2023-09-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-08-29 | 2023-09-15 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-29 | 2023-09-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-02-06 | N |
| 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 | 2023-01-13 | 2023-02-06 | 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 | 2023-01-13 | 2023-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-13 | 2023-02-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-06 | N |
| Meet other general requirements. | Fire Safety | 2021-11-09 | 2021-11-26 | 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 | 2021-11-09 | 2021-11-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-09 | 2021-11-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-09 | 2021-11-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-18 | 2021-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-18 | 2021-11-12 | 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 | 2021-10-18 | 2021-11-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-18 | 2021-11-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-18 | 2021-11-12 | N |
| 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 | 2021-10-18 | 2021-11-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-18 | 2021-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-18 | 2021-11-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-18 | 2021-11-12 | 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 | 2021-10-18 | 2021-11-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-18 | 2021-11-12 | 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 | 2021-10-18 | 2021-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-18 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-18 | 2021-11-12 | N |
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