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Deficiency Records for The Village at Mission
A list of the most recent deficiencies for The Village at Mission. 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 The Village at Mission. 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? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-12-20 | 2024-01-09 | 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 | 2023-12-20 | 2024-01-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-20 | 2024-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-25 | 2023-11-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-25 | 2023-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-25 | 2023-11-28 | 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 | 2023-10-25 | 2023-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-25 | 2023-11-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-25 | 2023-11-28 | N |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2023-10-25 | 2023-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-25 | 2023-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-25 | 2023-11-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-25 | 2023-11-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-25 | 2023-11-28 | Y |
| 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 | 2023-10-25 | 2023-11-28 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-04 | 2023-03-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-12-27 | 2023-01-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-27 | 2023-01-19 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-10-24 | 2022-10-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-24 | 2022-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-06-30 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Develop a communication plan. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| 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 | 2022-03-23 | 2022-04-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-23 | 2022-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-04-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-30 | 2022-04-08 | Y |
| 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 | 2022-03-30 | 2022-04-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-30 | 2022-04-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-17 | 2022-03-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-03-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-17 | 2022-03-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-17 | 2022-03-09 | Y |
| 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 | 2022-02-17 | 2022-03-09 | Y |
| 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 | 2022-02-17 | 2022-03-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-17 | 2022-03-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-17 | 2022-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-07-30 | 2020-08-24 | 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 | 2020-07-30 | 2020-08-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-07-30 | 2020-08-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-07-30 | 2020-08-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-07-30 | 2020-08-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-30 | 2020-08-24 | 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 | 2020-07-30 | 2020-08-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-07-30 | 2020-08-24 | 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 | 2020-07-30 | 2020-08-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-07-30 | 2020-08-24 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| 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 | 2020-02-04 | 2020-03-27 | 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 | 2020-02-04 | 2020-03-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-04 | 2020-03-27 | N |
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