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Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Clawson
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Clawson. 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 Mission Point Nsg and Phy Rehab Ctr of Clawson. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-13 | 2024-10-18 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-13 | 2024-09-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-13 | 2024-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-13 | 2024-09-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-25 | 2024-07-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-25 | 2024-07-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-25 | 2024-07-18 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-06-25 | 2024-07-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-05-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-17 | 2024-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-17 | 2024-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-07 | 2024-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-05-20 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-02-15 | 2024-05-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-02-15 | 2024-05-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-15 | 2024-05-20 | Y |
| 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 | 2024-02-15 | 2024-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-15 | 2024-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-15 | 2024-05-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-15 | 2024-05-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-05-20 | 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 | 2024-02-15 | 2024-05-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-15 | 2024-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-15 | 2024-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-27 | 2024-04-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-07 | 2024-04-01 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-14 | 2024-04-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-15 | 2024-03-26 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-15 | 2024-03-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-15 | 2024-03-26 | 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 | 2024-02-15 | 2024-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-15 | 2024-03-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-15 | 2024-03-26 | 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 | 2024-02-15 | 2024-03-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-15 | 2024-03-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-15 | 2024-03-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-15 | 2024-03-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-15 | 2024-03-26 | 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 | 2024-02-15 | 2024-03-26 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-15 | 2024-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-15 | 2024-03-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-15 | 2024-03-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-15 | 2024-03-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-15 | 2024-03-26 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-02-15 | 2024-03-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-08-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-13 | 2023-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-13 | 2023-08-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-13 | 2023-08-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-13 | 2023-08-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-13 | 2023-08-11 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-16 | 2023-04-20 | 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 | 2023-03-16 | 2023-04-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-16 | 2023-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-16 | 2023-04-13 | Y |
| 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 | 2023-03-16 | 2023-04-13 | Y |
| 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 | 2023-03-16 | 2023-04-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-04-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-16 | 2023-04-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-04-13 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-16 | 2023-04-13 | 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 | 2023-03-16 | 2023-04-13 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-16 | 2023-04-13 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-16 | 2023-04-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-03-16 | 2023-04-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-13 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-03-16 | 2023-04-13 | Y |
| 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 | 2023-03-16 | 2023-04-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-16 | 2023-04-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-06-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-06 | 2022-06-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-03-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-25 | 2022-02-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-25 | 2022-02-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-01-25 | 2022-02-22 | Y |
| 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 | 2022-01-25 | 2022-02-22 | Y |
| 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 | 2022-01-25 | 2022-02-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-25 | 2022-02-22 | Y |
| 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 | 2021-12-14 | 2022-01-21 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-14 | 2022-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide appropriate foot care. | Health | 2021-12-14 | 2022-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | 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 | 2021-12-14 | 2022-01-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-14 | 2022-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-14 | 2022-01-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-14 | 2022-01-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-14 | 2022-01-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | 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 | 2021-12-13 | 2022-01-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
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