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Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Warren
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Warren. 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 Warren. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-17 | 2024-09-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-13 | 2024-08-26 | 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 | 2024-07-03 | 2024-07-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-03 | 2024-07-20 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-27 | 2024-05-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-28 | 2024-04-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-28 | 2024-04-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-03-28 | 2024-04-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-28 | 2024-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-04-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-28 | 2024-04-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-28 | 2024-04-22 | 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 | 2024-03-28 | 2024-04-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-28 | 2024-04-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-28 | 2024-04-22 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-28 | 2024-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-28 | 2024-04-22 | 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 | 2024-03-28 | 2024-04-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-28 | 2024-04-22 | 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 | 2024-03-28 | 2024-04-22 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-03-28 | 2024-04-22 | 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 | 2024-03-28 | 2024-04-22 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-03-28 | 2024-04-22 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-03-28 | 2024-04-22 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-03-28 | 2024-04-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-03-28 | 2024-04-22 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-28 | 2024-04-22 | 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 | 2024-03-28 | 2024-04-22 | 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 | 2024-01-19 | 2024-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-19 | 2024-02-24 | 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 | 2024-01-19 | 2024-02-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-10 | 2024-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-10 | 2024-02-02 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-01-10 | 2024-02-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-20 | 2023-10-03 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-16 | 2023-02-11 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-12-21 | 2023-01-19 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-12-21 | 2023-01-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-21 | 2023-01-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-21 | 2023-01-19 | 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 | 2022-12-21 | 2023-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-21 | 2023-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-21 | 2023-01-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-21 | 2023-01-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-21 | 2023-01-19 | 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 | 2022-12-21 | 2023-01-19 | 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 | 2022-12-21 | 2023-01-19 | N |
| Provide or obtain dental services for each resident. | Health | 2022-12-21 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-21 | 2023-01-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-21 | 2023-01-19 | 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 | 2022-12-21 | 2023-01-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-21 | 2023-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-21 | 2023-01-19 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-12-21 | 2023-01-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-16 | 2023-01-19 | 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 | 2022-12-16 | 2023-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-16 | 2023-01-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-16 | 2023-01-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-16 | 2023-01-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-12-16 | 2023-01-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-16 | 2023-01-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-11-03 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-10-13 | 2022-11-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-08 | 2022-09-29 | Y |
| Provide appropriate foot care. | Health | 2022-09-08 | 2022-09-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-08 | 2022-09-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-21 | 2022-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-03 | 2022-03-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-03 | 2022-03-04 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-05-07 | 2021-06-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-05 | 2021-06-03 | N |
| 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 | 2021-05-05 | 2021-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-05 | 2021-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-05 | 2021-06-03 | 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 | 2021-05-05 | 2021-06-03 | 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 | 2021-05-05 | 2021-06-03 | 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 | 2021-05-05 | 2021-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-05 | 2021-06-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-05 | 2021-06-03 | 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 | 2021-05-05 | 2021-06-03 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-05-05 | 2021-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-05 | 2021-06-03 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-05 | 2021-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-05 | 2021-06-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-05 | 2021-06-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-07 | 2021-06-03 | N |
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