Eagle Point Nursing and Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food served at a palatable temperature and texture. The facility reported a census of 58 residents.Findings Include:During an interview on 04/20/2026 at 10:30 AM Resident #40 stated the facility only had one choice for some meals. The resident stated he cannot stand the pork chops as they are tough. Resident #40 stated the food could use improvement, and explained food had been service cold, overcooked and chewy making it difficult to eat. Resident #40 stated he had brought up his concerns to multiple staff but it continued to be a problem. During an interview on 04/20/2026 at 11:05 AM, Resident #18 stated the food can be cold at times. She stated she did not ask them to reheat and having food rewarmed in a microwave is not the same as getting food freshly cooked. Resident #18 added sometimes with dentures the food can be kind of hard to chew, and the meat can be dry and tough. During an interview on 04/20/2026 at 1:43 PM, Resident #4 stated the food is often dry or chewy like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, facility policy review and staff interviews,he facility failed to repair peeling paint in a resident's room in an effort to provide a comfortable environment for 1 of 2 residents (Resident #11) reviewed for homelike environment. The facility reported a census of 58 residents. Findings include: Review of Resident #11's Minimum Data Set (MDS) assessment, dated 4/09/26, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. During an interview on 4/21/26 at 12:37 PM, Resident #11 stated there were areas of the paint on the walls peeling off in her room. Resident #11 stated that a friend brought in a framed picture to hang on the wall in an attempt to cover an area of paint peeling. Resident #11 reported that in the bathroom of her room was a plastic strainer kept on the floor for months. The resident explained the strainer had been used when she passed kidney stones in November of 2025. During an observation in Resident #11's room on 4/21/26 at 12:37 PM, the East had 10 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to ensure staff used infection control techniques during wound care (Resident #10) and preparation of a dose of insulin when drawn up from a multiuse vial (Resident #57) for 2 of 5 residents reviewed for infection control. The facility reported a census of 58 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 2/20/26, revealed that Resident #10 had one unhealed Stage 3 pressure ulcer. The list of diagnoses included cutaneous abscess of buttocks, diabetes mellitus, and renal insufficiency.Review of the Care Plan, revised on 3/20/26, revealed a Focus area for Resident #10's potential/actual impairment to skin integrity started as an abscess, now pressure ulcer with the goal that Resident #10 will have complications related to area on buttocks through the review date. Interventions instructed the following, in part:a. Enhanced Barrier Precautions per Centers for Disease Control (CDC) recommendations. Date initiated: 9/09/25.b. Follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1st December 31), facility record review, and staff interviews the facility failed to submit accurate staffing data for the PBJ Staffing Data Report. The facility reported a census of 53 residents. Findings include: The PBJ report from the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Roster (nursing assignment) dated 12/28/24, identified the Minimum Data Set (MDS) nurse worked the 2-10 shift due to a call off for for the 2-10 shift. The Daily Roster dated 12/29/24, showed the Assistant Director of Nursing (ADON) worked the day shift and the MDS nurse worked the 2-10 shift due to a nurse called off for a double shift. The Facility assessment dated 1/2025, reflected the Staffing Plan, other nursing personal (those with administrative duties that are not part of direct care like the Director of Nursing (DON), ADON and MDS. On 4/02/25 at 1:01 PM, the DON reported on 12/29/24 (Sunday) the ADON worked due to a call off for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review the facility failed to specify and maintain appropriate water temperatures in order to prevent legionella growth or use appropriate personal protective equipment (PPE) when laundering contaminated items. In addition, the facility failed to use a barrier when emptying the catheter bag for 2 of 2 residents reviewed (Residents #13 and Res #32). The facility failed to utilize enhanced barrier precautions when completing wound care on 1 out 3 wound cares observed (Resident #44). The facility reported a census of 52 residents. Findings include: 1. On 6/5/24 at 9:03 AM watched Staff B, Laundry/Housekeeping, wear gloves, failed to wear a gown when transferring soiled linens from a red bin (contaminated items) to the washing machine. On 6/5/24 at 9:07 AM Staff B confirmed she only wore gloves for handling linens, she didn't wear a gown or mask with contaminated linens. They used to do that during the Covid 19 pandemic but not anymore. On 6/5/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, resident and staff interview, the facility failed to maintain a homelike environment for resident rooms for six out of six rooms reviewed. (Residents #5, #6, #31, #40, #45). The facility reported a census of 52 residents. Findings include: Observations of residents' rooms revealed the following: a. On 6/3/24 10:31 AM, Resident #5's bathroom door had approximately 40% of the paint missing from the bottom. Resident #5 reported the door to her bathroom looked that way since she moved in 3 years ago. In addition, the wall outside the door on the left side didn't have a baseboard. b. On 6/4/24 at 7:29 AM, Resident #40's bathroom door had splintering noted to bottom portion of the door. c. On 6/4/24 at 8:04 AM, Resident #45's bathroom door had paint missing to the lower portion, a baseboard missing to left side of the door, and corner covers peeled off with exposed plaster which measured approximately 4 feet in length. d. On 6/5/24 at 8:12 AM, Resident #6's bathroom door had paint missing to top portion of the door and the wall to right side of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to identify resident problems and implement appropriate interventions on the Care Plans for four of four residents reviewed (Residents #13, #21, #31, and #34). The facility reported a census of 52 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #13 required substantial/maximal staff assistance with dressing and required total assistance from staff with toilet use, showers, putting on and taking off footwear. In addition, the MDS also identified Resident #13 had an indwelling catheter and colostomy. The MDS included diagnoses of diabetes mellitus, paraplegia (paralysis of one half of the body) and arthritis. The Order Summary Report dated 6/4/24 included an order dated 12/28/22 for Ozempic (0.25 or 0.5 milligrams MG/dose) Solution Pen injector 2 MG/1.5 ml. Inject 0.25 MG subcutaneously in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F 698 Dialysis SS=D Based on record review, resident and staff interview, and policy review the facility failed to conduct assessments of the dialysis access site and conduct post dialysis vitals for 1 of 1 resident reviewed (Res #21). The facility reported a census of 52 residents. Findings include: Resident #21 Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of end stage renal disease, anemia, and diabetes mellitus. The MDS indicated Resident #21 received dialysis as a resident at the facility. Resident #21's Care Plan dated 11/2/23 lacked information related to his dialysis. The Dialysis Agreement form dated 6/5/22 with the local health center documented the resident receives dialysis three days per week. Resident #21's electronic medical record lacked documentation of assessments of the access site pre and post dialysis or post dialysis vitals. The Dialysis Communication notes from 3/4/24 to 6/3/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, family, and staff interview, the facility failed to document an assessment of a resident prior to their transfer to the hospital for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 52 residents. Findings include: Resident #6 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. Resident #6 required total assistance from staff with most activities of daily living. The MDS included diagnoses of renal insufficiency (kidney failure), diabetes mellitus and non Alzheimer's dementia. On 6/3/24 at 10:03 AM witnessed Resident #6 sit in her recliner, awake, alert, and able to converse with the staff. Resident #6 denied pain, discomfort, or problems with cares. She looked properly positioned and comfortable. On 6/3/24 at 1:05 PM, Resident #6's family member reported Resident #6 got hospitalized in January 2024 due to influenza A. The Nurses Note dated 1/3/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.