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Deficiency Records for Eastpointe Rehab Center
A list of the most recent deficiencies for Eastpointe Rehab 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 Eastpointe Rehab 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-10 | 2024-06-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-22 | 2024-05-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-22 | 2024-05-29 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-04-22 | 2024-05-29 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-04-22 | 2024-05-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-04-22 | 2024-05-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-22 | 2024-05-29 | 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 | 2024-04-22 | 2024-05-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-22 | 2024-05-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-22 | 2024-05-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-22 | 2024-05-29 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-22 | 2024-05-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-04-22 | 2024-05-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-22 | 2024-05-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-05-29 | 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 | 2024-04-22 | 2024-05-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-22 | 2024-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-22 | 2024-05-29 | N |
| 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 | 2024-04-22 | 2024-05-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-22 | 2024-05-29 | 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 | 2024-04-22 | 2024-05-29 | 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 | 2024-04-22 | 2024-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-22 | 2024-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-22 | 2024-05-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-22 | 2024-05-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-04-22 | 2024-05-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-04-22 | 2024-05-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-22 | 2024-05-29 | 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 | 2024-01-26 | 2024-02-23 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-01-26 | 2024-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-26 | 2024-02-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-29 | 2024-01-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-29 | 2024-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-01 | 2023-09-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-01 | 2023-09-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-01 | 2023-09-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-06-08 | Y |
| 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 | 2023-04-27 | 2023-06-08 | 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 | 2023-04-27 | 2023-06-08 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-04-27 | 2023-06-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-27 | 2023-06-08 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-13 | 2023-03-29 | 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 | 2023-02-02 | 2023-03-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-03-13 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-03-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-02 | 2023-03-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-02 | 2023-03-13 | N |
| Post nurse staffing information every day. | Health | 2023-02-02 | 2023-03-13 | 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 | 2023-02-02 | 2023-03-13 | 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 | 2023-02-02 | 2023-03-13 | 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 | 2023-02-02 | 2023-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-03-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-14 | 2022-10-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-14 | 2022-10-24 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-09-14 | 2022-10-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-14 | 2022-10-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-28 | 2021-09-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-28 | 2021-09-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-28 | 2021-09-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-28 | 2021-08-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-28 | 2021-08-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-28 | 2021-08-13 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-28 | 2021-08-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-28 | 2021-08-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-28 | 2021-08-13 | 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 | 2021-06-28 | 2021-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-28 | 2021-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-28 | 2021-08-13 | N |
| 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 | 2021-06-28 | 2021-08-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-28 | 2021-08-13 | 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 | 2021-06-28 | 2021-08-13 | 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 | 2021-06-28 | 2021-08-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-28 | 2021-08-13 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-07-01 | 2021-08-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-01 | 2021-08-06 | N |
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