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Mission Point Nsg & Phy Rehab Ctr Of Hancock

Inspection Results

Nursing Homes Michigan Hancock Mission Point Nsg & Phy Rehab Ctr Of Hancock

Mission Point Nsg & Phy Rehab Ctr Of Hancock has been cited for a total of 128 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Mission Point Nsg & Phy Rehab Ctr Of Hancock.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 440 nursing homes in Michigan with a total of 33,399 deficiencies resulting in an average of 75.91 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2023-07-14
Corrected:
2023-08-14
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Hire a qualified full-time social worker in a facility with more than 120 beds.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
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.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Hire a qualified full-time social worker in a facility with more than 120 beds.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-14
Corrected:
2022-10-14
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-02
Corrected:
2022-06-27
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-08-24
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-11-02
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-02
Corrected:
2022-06-27
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-08-24
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-07-29
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-06-27
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-06-02
Corrected:
2022-11-02
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2022-01-04
Corrected:
2022-01-28
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2022-01-04
Corrected:
2022-01-28
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-16
Corrected:
2022-02-16
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-12
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-12
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Put firmly secured handrails on each side of hallways.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-12
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-12
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Put firmly secured handrails on each side of hallways.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-08
Corrected:
2021-03-09
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2020-07-31
Corrected:
2020-08-28
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2020-07-31
Corrected:
2020-08-28
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
N
Survey Date:
2020-06-19
Corrected:
2020-07-24
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-16
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-16
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-02
Corrected:
2019-05-08

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