Trailpoint Village

Based on observation, record review and interviews, the facility failed to updated/revise a comprehensive person-centered care plan for nutritional needs related to continued weight loss (Resident B), for 1 of 21 residents reviewed for care plans.Finding includes:During an interview, with Resident B's daughter, she indicated she had a concern regarding her mother's ongoing weight loss.On 4/10/2026 at 9:01 A.M., Resident B's medical record was reviewed. Diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease, depression, anxiety, and osteoporosis.A Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2026, indicated Resident B had severe cognitive impairment, required set up assistance for eating and had experienced a weight loss of 5% or more in the past month and 10% or more in the past 6 months.Resident B weighed 130 pounds on October 1, 2025. However, by November 18, 2025 she had lost weight and only weighted 120 pounds which resulted in an over 7.5% weight loss in a little over a month. A Care Plan initiated, on 12/20/2024 and updated on…

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 record review and interview, the facility failed to initiate a recommended restorative program after therapy for 1 of 1 resident reviewed for rehabilitation. (Resident 14)Finding includes:During an interview, on 4/8/2026 at 1:45 P.M., Resident 14 indicated she was able to walk prior to surgery, had received rehabilitation, but the insurance company had cut her therapy. Resident 14 indicated she could now only walk a few steps to get to the toilet, and the therapy department have been planning to start a restorative program for ambulation. A record review for Resident 14 was completed on 4/9/2026 at 11:00 A.M. Diagnoses included, but were not limited to: chronic pain constipation, conversion disorder with seizures or convulsions and chronic obstructive pulmonary disease (COPD). An Annual Minimum Data Set (MDS) assessment, dated 3/23/2026, indicated Resident 14 was cognitively intact, had no extremity impairment, required partial/moderate assistance for walking 10 feet and walking 50 feet was not attempted due to her medical condition and/or safety. A Physician's Order, dated…

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, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, related to the omission of prescribed doses and medications for 4 of 31 medications observed during medication administration. These medication errors resulted in an error rate of 7.75% (Residents 39 & 112). Findings include:1. During a medication administration observation, on 4/10/2026 at 8:34 A.M., RN 3 prepared medications for Resident 39. She prepared the following medications:-bupropion hydrochloride 300 milligrams one tablet-calcium-Vitamin D3 600 milligram-10 microgram one tablet- ferrous fumarate 325 milligrams one tablet- fluoxetine 20 milligrams one tablet- magnesium oxide 400 milligrams one tablet- omeprazole 20 milligrams one capsule- multivitamin one tablet- liquid protein 30 milliliters- pregabalin 100 milligrams one capsule A record review for Resident 39 was completed on 4/10/2026 at 9:02 A.M. Resident 39 had orders for lactobacillus acidophilus 10 billion cell 1 tablet. The medication had not been administered during the medication pass…

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 interview and record review, the facility failed to ensure 1 of 3 residents reviewed for abuse was free from abuse, when a previous staff member verbally abused the resident while exiting the facility following her resignation, (Resident C). Finding includes: On 8/14/25 at 12:00 P.M., Resident C's clinical record was reviewed. Diagnoses included but were not limited to osteomyelitis, type 2 diabetes with diabetic polyneuropathy, and spinal stenosis. Resident C's Care Plans included but were not limited to, Resident displays verbal aggression towards others when feeling frustrated with them, initiated on 7/30/25. Review of a facility Incident Number 668, reported to the State Agency on 8/8/25, indicated on 8/8/25 at 4:01 P.M., Resident C reported that the previous Unit Manager, Licensed Practical Nurse (LPN) 5, went up to him on her way out of the facility and spoke rudely to him after telling him she had quit. The staff member had resigned and was terminated from the system when an investigation was initiated. All appropriate parties were notified. Staff and residents were…

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, interview and record review, the facility failed to prevent the misappropriation of narcotics for 1 of 4 residents receiving narcotics reviewed. (Resident C) Finding includes: On 6/12/25 at 12:16 P.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to: respiratory failure with hypoxia-tracheostomy, diabetic neuropathy, dysphagia (difficulty swallowing), diabetes and chronic kidney disease. A current Care plan for pain, initiated on 4/28/25, indicated the resident was at risk for pain related to impaired mobility and diabetic neuropathy. The interventions included, but were not limited to: notify physician if pain is unrelieved and/or worsening, assist with positioning to comfort, administer medications as ordered and document effectiveness of pain medications. A Nursing Progress Note, dated 5/15/25 at 7:56 A.M., indicated the previous shift had reported the resident's narcotics had been held since 2:00 P.M. on 5/14/25. In addition, they had reported the resident had slept most 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.

Based on interview and record review the facility failed to ensure staff members acted competently and followed facility protocol regarding notification and assessment of a licensed nurse after a resident experienced a fall prior to moving the resident for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 6/12/25 at 1:28 P.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: chronic respiratory failure with dependence on ventilator, artificial opening of gastrointestinal tract-gastrojejunostomy tub (G-tube), cerebral palsy, paraplegia, and an anxiety disorder. A Fall Event form, dated 5/29/25 at 5:10 P.M., indicated CNA 3 reported the resident had fallen out of the side of the Hoyer pad during a transfer. CNA 3 reported she had used her body to guide the resident's fall to the floor. The Respiratory Manager had assisted CNA 3, immediately after the fall, with positioning the Hoyer pad back underneath the resident and then assisted to transfer Resident B back into his bed. The form indicated…

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, interview and record review, the facility failed to ensure medications were labels and stored according to professional priniciples on 3 of 4 medication carts observed. (Memory Care, 100 Hall & 400 Hall) Findings include: 1. On 2/27/2025 at 9:30 A.M., a medication storage observation was completed with RN 2 on the Memory Care cart, the following was observed: An opened, undated and unlabeled bottle of calcium magnesium with zinc capsules. In addition, there was a bottle of One a Day Men 50 + vitamin supplement with only a resident's first name written on the lid of the bottle. During an interview on 2/27/2025 at 9:40 A.M., RN 2 indicated a family member had brought them in and the bottles should have had labesl and an opened date on them. 2. On 2/27/2025 at 10:47 A.M., a medication storage observation was completed with RN 3 on the 100 Hall cart and the following was observed: Three bottles of prescirption eye drops were stored the same drawer as oral medications. One of three bottles of eye drops was not labeled with complete instructions regarding which eyes…

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 record review and interview, the facility failed to ensure advanced directives were coordinated with hospice for 1 of 2 residents reviewed for hospice services. (Resident 28) Finding includes A record review for Resident 28 was completed on 2/26/2025 at 9:45 A.M. Diagnosis included, but were not limited to occlusion and stenosis of right posterior cerebral artery, metabolic encephalopathy, dementia, schizoaffective, borderline personality, bipolar, and aortic stenosis. A Physicians Order dated 11/25/2024, indicated the resident was a full code. Resident 28's care plan, initiated on 11/26/2024, indicated the resident and/or the resident's legal representative preferred a full code status. A Physician's Order dated 2/11/2025 indicated an order for hospice for Resident 28 for end of life care. Review of the hospice initial plan of care, dated 2/10/2025, indicated an advanced directives of Do Not Resuscitate (DNR) code status. A Physician Orders for Scope of Treatment (POST) form, signed on 2/10/2025 indicated Resident 28's code status was now a DNR. The facility was not…

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 observation and interview the facility failed to ensure food preparation areas and equipment was clean and that food was stored in a sanitary manner. The facility failed to ensure employees utilized hygienic practices when handling food delivery items, and washed their hands after handling the trash receptacle. This had the potential to affect all residents receiving food from the kitchen. Findings include: 1. During an initial observation of the kitchen with the Dietary Manager (DM), on 2/26/2024 at 9:45 A.M., the handwashing sink was dirty. Vents in the ceiling were dirty with dust collected in the slats. Pans used in the steam table were stacked together wet. The oven had a burnt substance on the bottom. The sneeze guard on the steam table was dirty with food substances dripping down. During an interview, on 2/26/2024 at 10:00 A.M., the DM indicated the handwashing sink, oven, and sneeze guard should have been clean, the vents in the ceiling were going to be replaced, and the pans should have been dry before stacking. 2. During an observation of the kitchen with the DM, on…

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, and interview, the facility failed to ensure medication storage areas were free from loose pills, failed to date medications when opened, and failed to ensure a medication refrigerator was free from ice buildup, for 4 of 6 medication storage areas observed. (#1 & #2 400 Hall medication carts, 100 Hall medication cart, & medication room) Findings include: 1. A medication storage observation on the #1 400 hall medication cart was completed on 2/27/2024 at 2:36 P.M., with LPN 7. There were 2 loose pills in the cart. During an interview, on 2/27/2024 at 2: 39 P.M., LPN 7 indicated the loose pills should not be in the drawer. 2. During a medication storage observation, on 2/27/2024 at 2:45 P.M., on the #2 400 hall medication cart with RN 8, the following was observed: - An opened and undated bottle of guaifenesin. - An opened and undated bottle of Robitussin. During an interview, on 2/27/2024 at 2:52 P.M., RN 8 indicated the medications should be dated when opened. 3. A medication storage observation on the 100 hall medication cart was completed on…

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 interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling out of bed during care, for 1 of 4 residents reviewed for accidents. (Resident 34) Finding includes: During an interview, on 2/27/2024 at 8:58 A.M., Resident 34 indicated he had fallen out of bed about two months ago during care, and was sent to the hospital. A record review for Resident 34 was completed on 2/28/2024 at 3:16 P.M. Diagnoses included, but were not limited to: morbid obesity, chronic respiratory failure, dependence on a ventilator, and chronic kidney disease. A Significant Change MDS (Minimum Data Set) assessment, dated 12/10/2023, indicated the resident required extensive physical assistance from two staff members for bed mobility and toilet use, required supervision with set-up help for eating, and transferring occurred 1-2 times with 2 or more staff assist. An admission MDS assessment, dated 1/25/2024, indicated the resident was cognitively intact. A Care Plan, dated 6/5/2019, indicated the resident required the assist of 2 staff members for…

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, and interview, the facility failed to properly store a BIPAP mask to prevent contamination, for 1 of 5 residents reviewed for respiratory care. (Resident 56) Finding includes: During an observation, on 2/27/24 at 10:43 A.M., Resident 56's oxygen mask was laying on her bedside table outside of a bag, and the mask appeared dirty with an oily substance noted around the seal. During an observation, on 2/29/24 at 2:31 P.M., Resident 56's BIPAP mask was laying on the table and not in a bag. The mask had a dirty substance around the seal. During an observation, on 3/1/2024 at 9:11 A.M., Resident 56's BIPAP mask was laying on the bedside table and not in a bag. The mask remained dirty around the seal. A record review for Resident 56 was completed on 2/28/24 at 2:43 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, type 2 diabetes, dementia, quadriplegia, and hypertension. A Quarterly MDS (Minimum Data Set) assessment, dated 12/19/23, indicated Resident 56 had moderate memory impairment. A Physician's Order, dated…

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 interview and record review, the facility failed to ensure a clean, safe, and sanitary environment for 1 of 3 resident reviewed environment. (Resident B) Findings include: On 8/25/23 at 1:00 P.M., the clinical record for Resident B was reviewed. The resident's Face Sheet, indicated he was most recently admitted to the facility on [DATE], with diagnoses that included pneumonia, stroke, gastrostomy, chronic obstructive pulmonary disease, and chronic respiratory failure. Resident B's admission Minimum Data Set (MDS) assessment, dated 6/21/23, indicated the resident was admitted to room [ROOM NUMBER] on 6/15/23. On 8/28/23 at 11:08 A.M., a facility grievance dated 6/15/23 at 3:00 P.M., was provided by the Administrator and indicated, Resident B's wife complained that room [ROOM NUMBER] was filthy and there were bugs everywhere. The grievance indicated the Director of Marketing and Admissions looked at room [ROOM NUMBER] and found garbage in the trash and floors were dirty and bugs were in the room and 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.