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Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Elmwood
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Elmwood. 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 Elmwood. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-07 | 2024-12-05 | 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 | 2024-08-07 | 2024-11-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-08 | 2024-09-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-08 | 2024-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-08 | 2024-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-08 | 2024-09-30 | 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 | 2024-08-08 | 2024-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-08 | 2024-09-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-08-08 | 2024-09-30 | N |
| Provide or obtain dental services for each resident. | Health | 2024-08-08 | 2024-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-08 | 2024-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-08 | 2024-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-08 | 2024-09-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-08-07 | 2024-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-08 | 2024-03-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-04 | 2024-02-01 | 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 | 2023-10-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-20 | 2023-10-10 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-08-02 | 2023-09-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-02 | 2023-09-15 | 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 | 2023-08-02 | 2023-09-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-02 | 2023-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-09-15 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-02 | 2023-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-15 | N |
| Keep all essential equipment working safely. | Health | 2023-08-02 | 2023-09-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-02 | 2023-09-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-02 | 2023-09-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-01 | 2023-09-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-15 | 2023-07-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-15 | 2023-07-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-21 | 2022-06-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-22 | 2022-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-22 | 2022-06-03 | 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 | 2022-04-22 | 2022-06-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-22 | 2022-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-22 | 2022-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-22 | 2022-06-03 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-22 | 2022-06-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Meet other general requirements. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-21 | 2022-06-03 | N |
| 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 | 2021-12-01 | 2021-12-27 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-12-01 | 2021-12-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-01 | 2021-12-27 | Y |
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