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Deficiency Records for Mission Point Nsg and Phy Rehab Ctr of Hancock
A list of the most recent deficiencies for Mission Point Nsg and Phy Rehab Ctr of Hancock. 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 Hancock. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-07 | 2024-09-25 | 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 | 2024-08-12 | 2024-09-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-12 | 2024-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-12 | 2024-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-12 | 2024-09-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-08-12 | 2024-09-12 | 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 | 2024-08-12 | 2024-09-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-08-12 | 2024-09-12 | N |
| Post nurse staffing information every day. | Health | 2024-08-12 | 2024-09-12 | 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 | 2024-08-12 | 2024-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-12 | 2024-09-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-08-12 | 2024-09-12 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-08-12 | 2024-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-12 | 2024-09-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-08-12 | 2024-09-12 | 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 | 2024-08-12 | 2024-09-12 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-08-12 | 2024-09-12 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-08-12 | 2024-09-12 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-08-12 | 2024-09-12 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-08-12 | 2024-09-12 | 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 | 2024-08-12 | 2024-09-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-08-07 | 2024-09-12 | 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 | 2024-08-07 | 2024-09-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-07 | 2024-09-12 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-05-01 | 2024-06-07 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-05-01 | 2024-06-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-01 | 2024-05-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-03 | 2024-04-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-03 | 2024-04-26 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-13 | 2023-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-13 | 2023-08-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-08-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-14 | 2023-08-14 | 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 | 2023-07-14 | 2023-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-14 | 2023-08-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-14 | 2023-08-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-14 | 2023-08-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-14 | 2023-08-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-08-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-13 | 2023-08-14 | 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 | 2023-07-13 | 2023-08-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-13 | 2023-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-11-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-14 | 2022-10-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-14 | 2022-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-14 | 2022-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-09-14 | 2022-10-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-14 | 2022-10-14 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-09-14 | 2022-10-14 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-14 | 2022-10-14 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-09-14 | 2022-10-14 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-09-14 | 2022-10-14 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-09-14 | 2022-10-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-25 | 2022-09-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-25 | 2022-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-25 | 2022-09-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-02 | 2022-08-24 | 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 | 2022-06-02 | 2022-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-02 | 2022-07-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-07-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-02 | 2022-07-29 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-25 | 2022-07-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-25 | 2022-06-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-02 | 2022-06-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-02 | 2022-06-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-06-02 | 2022-06-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-02 | 2022-06-27 | 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 | 2022-06-02 | 2022-06-27 | N |
| Post nurse staffing information every day. | Health | 2022-06-02 | 2022-06-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-02 | 2022-06-27 | 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 | 2022-06-02 | 2022-06-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-25 | 2022-06-27 | 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 | 2022-05-25 | 2022-06-27 | 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 | 2022-05-25 | 2022-06-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-25 | 2022-06-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Develop a communication plan. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-25 | 2022-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-16 | 2022-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-02-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-16 | 2022-02-16 | 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 | 2022-01-04 | 2022-01-28 | Y |
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