Oakpointe Senior Care and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation contains two Deficienct Practice Statements Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to ensure that staff followed enhanced barrier precautions (EBP) and donned appropriate Personal Protective Equipment (PPE) for one resident (R1) out of two residents reviewed for EBP. This failure resulted in the potential for transmission of infectious organisms. Findings include: On 06/10/25 at 11:12 A.M., during an observation of resident care, licensed practical nurse (LPN) B was observed administering a 100 ml (milliliter) water flush through R1's percutaneous endoscopic gastrostomy (PEG) tube. LPN B did not don a gown prior to providing the care. Signage on R1's door indicated Enhanced Barrier Precautions and PPE (including gowns) being available outside R1's room. An interview was conducted with LPN B immediately following the observation. LPN B acknowledged that they should have worn a gown and gloves while administering the PEG tube flush and…

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 upon interview and record review, the facility failed to act upon Pharmacy Recommendations in a timelly manner regarding discontinuing blood sugar checks four times a day for one (R92) of five residents reviewed for unnecessary medication regimen reviews, resulting in unnecesary monitoring and the potential for R92 to experience discomfort during multiple finger sticks. Findings include: According to R92's Electronic Health Record (EHR) the resident had multiple diagnoses that included type 2 diabetes (adult onset diabetes) without complications. On 4/11/24 the physician prescribed the following insulin orders: Novolog (fast acting insulin) injection per sliding scale (varies the dose of insulin injection based on the blood sugar level) before meals and at bedtime (4 times a day) as follows; for blood sugar reading; 0-200 = zero units of insulin, 201-250 = 1 unit of insulin, 251-300 = 2 units of insulin, 301-350 = 3 units of insulin, 351-400 = 5 units of insulin, and 401- 450 = 5 units of insulin, if over 450 call the physician. The Pharmacy Recommendation for R92 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 follow the Standards of Practice during medication administration for three of five residents (R18, R68, and R52) resulting in the potential for medication errors. Findings include: Resident 52 On 6/12/24 at 9:14 AM on the 1 North Hall, Registered Nurse (RN) H was observed standing at the medication cart looking at the computer screen. There was a medication cup with 6 white pills of various shapes sitting on top of the medication cart. There were 2 separate pills inside white plastic pharmacy packaging identified as 'Lasix 20 milligrams (mg)'. There was no resident's name on the packaging. During interview RN H said she was going to pass the 6 pills in the medication cup to R52 but the medications did not match up to what was on R52's Medications Administration Records (MAR). RN H said she had just taken the medication cart from Licensed Practical Nurse (LPN) J and the pills were already in the cup. RN H confirmed she did not put the pills in the medication cup herself, did not know which resident's…

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, interview, and record review the facility failed to clarify an order for compression stockings per physician orders for one (R27) of one resident reviewed for compression stockings resulting in edema and the potential for increased compromised of R27's cardiovascular system. Findings include: On 6/11/2024 at 12:56 P.M., R27 was observed seated in a wheelchair in her room with her feet on the floor. During the observation R27 complained her feet were swollen and nothing had been done even though the concern had been observed and reported to staff. R27's feet were observed during the interview and appeared very swollen. At 2:00 P.M. during an observation on the unit, R27 stated, her feet had gotten worse, and her friend had brought a pillow into the facility to elevate her legs but that was difficult to do since the right leg rest of the wheelchair was removed and left under the bed. R27 stated, her feet started swelling about two-three weeks ago and both were worse at night or evening once…

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, interview, and record review the facility failed to follow recommendations for restorative therapy for one resident (R89) out of three residents reviewed for positioning, resulting in the potential for contractures (shortening and hardening of muscles, tendons, and tissues). Findings include: During an observation and interview on 6/11/24 at 11:45 AM, R89 was observed sitting in a geri chair unable to move left side of body. Family Member G reported that R89 needed continued therapy. Record review of R89's electronic medical record (EMR) revealed admission into the facility on 4/25/24 with a diagnosis of hemiplegia/hemiparesis (paralysis) related to cerebral infarction (stroke). According to the Minimum Data Set (MDS) dated [DATE], R89 had impaired cognition and required substantial/maximal assistance with most Activities of Daily Living (ADLS). Record review of Restorative Nursing Referral dated 6/6/24 documented the following: Frequency: 2 times daily per Resident's tolerance for 8 wks…

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, interview, and record review, the facility failed to secure smoking materials and complete a smoking assessment for one (R82) of one resident reviewed for smoking safety, accident, and hazards, resulting in the potential for injury to self and other residents. Findings include: In an observation on 6/11/24 at 11:27 a.m., a hand held cigarette lighter sat on top of a phone on R82's bedside table. R82 reported not having any cigarettes and is not currently smoking. R82 then reported getting the lighter from a family member and it usually is put in a purse. In an observation and interview on 6/11/24 at 11:38 a.m., Life Enrichment Director D reported cigarettes and lighters should be stored at the front desk. Life Enrichment Director D was asked should R82 have a lighter in the room. Review of an admission Record revealed, R82 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included hemiplegia and hemiparesis (paralysis) of the right side.…

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 post nurse staffing information for all 98 residents as well as visitors entering the facility, resulting in the necessary staffing information not being available. Findings include: On 6/11/24 at 9:30 A.M., behind the front receptionist desk in the lobby area a posted board was labeled with the facility's name and smudged out numbers and information related to nurse staffing. Observations on 2:30 P.M. and again at 4:30 P.M., revealed the nurse staffing board had the same smudged out information. The facility's nurse staffing numbers were not clearly visible. On 6/12/24 at 12:30 P.M. and 4:00 P.M., the nurse staffing board remained in the same condition as the previous day. On 6/13/24 at 10:00 A.M. the nurse staffing board had not been updated or changed. At 11:00 A.M., the Administrator was queried if the board in the front lobby was where the facility posted nurse staffing information. The Administrator identified the same board in the front lobby and stated Supervisor O was responsible for updating 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 observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors out of 26 opportunities for error were observed for two (R18 and R68) out of five residents reviewed during the medication administration observation, resulting in a 7.69% error rate. Findings include: Resident 18 On 6/12/24 at 9:38 AM, Registered Nurse (RN) H was observed to administer medications to R18 during the AM dose. RN H was observed to deliver two puffs of the following inhaler; Breo-Ellipta Aerosol Powder Breath Activated 200-25 micrograms (mcg) ACT. According to R18's physician's order dated 4/24/24 and the Medication Administration Record (MAR) for June 2024, R18 was prescribed Breo-Ellipta Inhalation Aerosol Powder Breath Activated 200-25 mcg ACT one puff inhale orally in the morning. Resident 68 On 6/12/24 at 10:15 AM Licensed Practical Nurse (LPN) J along with LPN I was observed to administer medications to R68 during the AM dose. LPN J said she was in orientation and LPN I was training her. During medication…

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, interview, and record review the facility failed to ensure that one resident (R68) was free from significant medication errors out of five residents reviewed for medication errors resulting in R68 only receiving half the prescribed dose of anti-anxiety medications for 4 consecutive doses. Findings include: According to R68's Electronic Health Record the resident had multiple diagnoses that included malignant neoplasm of the brain, generalized anxiety disorder, and major depressive disorder. On 5/21/24 the resident was admitted to Hospice care. R68's Minimum Data Set, dated [DATE] indicated that R68 had intact cognition with a brief interview for mental status (BIMS) score of 14/15. According to R68's physician's order dated 5/31/24 and Medication Administration Record (MAR) for June 2024, R68 was prescribed Ativan 1.0 milligram (mg) by mouth two times a day at 9:00 AM and 9:00 PM. On 6/12/24 at 10:15 AM, Licensed Practical Nurse (LPN) J along with LPN I was observed to administer…

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, interview, and record review the facility failed to follow the standards of infection control for proper glove use and hand hygiene, for two residents (R2 and R308) out of 20 sampled residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: R2 Review of an admission Record revealed, R2 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Dementia and Type II Diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12 out of 15. R308 Review of an admission Record revealed, R308 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Type II Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Malignant Neoplasm (cancer) of…

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 utilize essential equipment to ensure a functional call light system resulting in call lights not answered in a timely manner, unmet care needs, and the potential delay in responding to emergency situations. This had the potential to affect all residents in the facility that utilize the call light. Findings include: On 6/28/23 at 10:26 a.m. during the initial pool process, R42 was observed resting in bed. The resident was alert, oriented x3, and able to make all needs known. During the interview, R42 voiced concerns with long call light response time, I have sat in bm (bowel movement) for three hours before. Sometimes I just want a cup of water and have to wait a long time. If I was having a heart attack, I could be dead before they would know. I have to flag someone down if they walk by the room to get their attention. They used to have pagers to let them know to come to the room. Now they have to look on the board at the nurse's station. R42 was asked did the facility give a hand-held bell to use. R42…

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.

This citation pertains to intakes MI00130262 and MI00133274. Based on observation, interview, and record review, the facility failed to ensure medication was administered properly and per physician's orders for one resident (R35) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation on 6/28/23 at 11:52 a.m., R35 laid in bed. A medication cup with multiple pills sat on R35's bedside table. R35 stated, this is something new, the nurse usually stands here to make sure I take the medication. In an observation and interview on 6/28/23 at 11:54 a.m., Licensed Practical Nurse (LPN) C reported medication should not be left at bedside. R35 reported she was sleeping and did not see the nurse bring in the medication. LPN C then stood by while R35 take the medication. LPN C acknowledged that she was not the assigned nurse for R35. Review of an admission record revealed, R35 admitted to the facility 10/25/21 with…

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 administer medications accurately for two residents (R8 and R96) out of five residents during medication pass, resulting in a medication error rate of 13.79 %. Findings include: Resident #38 (R38) In an observation on 6/29/23 at 8:01 a.m., Registered Nurse (RN) A prepared medication for R38. RN A placed 10 medications in a cup which included, Digoxin (used to treat Atrial Fibrillation). RN A did not place Protonix (used to treat heartburn) in the mediation cup. In an observation on 6/29/23 at approximately 8:10 a.m., RN A entered R38's and obtained a blood pressure on a vital machine. R38's blood pressure was 118/71 and heart rate 57. R38 took the medication with water. RN A then exited the room and documented the medication administration. In an interview on 6/29/23 at 8:19 a.m., RN A reported R38 did not receive Protonix because it should be given at 6:00 a.m. Review of an admission record revealed, R38 admitted to the facility 1/30/22 with pertinent diagnosis which included Type 2 Diabetes and Atrial…

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 properly disinfect a Glucometer (medical device for determining the concentration of glucose in the blood) for one (R38) out of five residents reviewed for medication administration, resulting in the potential for the spread of infection. Findings include: In an observation on 6/29/23 at 7:35 a.m., Registered Nurse (RN) A prepared supplies to perform a blood glucose check for Resident #38 (R38). RN A placed a glucometer, strips, lancet, and alcohol swab on a tray and entered R38's room. RNA wiped R38's finger with a alcohol swab, poked finger with a lancet, and applied blood to the strip in glucometer. RN A cleaned up supplies and exited the room. In an observation on 6/29/23 at 7:38 a.m., RN A wiped the front of the Glucometer with a alcohol swab and placed it on medication cart without a barrier. In an interview on 6/29/23 7:40 a.m., RN A reported the Glucometer is cleaned with a alcohol swab. RN A then stated, we have bleach wipes, but I do not use them until after all the blood sugars are taken. Review of…

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.