Mission Point Nursing & Physical Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update and revise care plan interventions for 1 Resident (#7) of 12 residents reviewed for care plan revision, resulting in the potential for unmet resident care needs, increased falls, unsafe resident environment, and resident injury. Findings include:Resident #7 (R7)Review of the admission Record Face Sheet revealed R7 was admitted to the facility on [DATE] with diagnoses including repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had a brief interview for mental status (BIMS) score of 13 out of 15, indicating cognition was intact. In an interview on 7/24/2025 at 8:51 AM, R7 reported he had fallen out of bed quite a few times trying to reach for things, or self-transfer. R7 reported he has not been injured but does have pain in his right elbow from a car accident he was in many years ago. Review of R7's Care Plan revealed: Focus At risk for falls aeb (as evidence by) impaired gait and mobility r/t (related 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, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care i.e. bathing and grooming services for one Resident (R5) of two residents reviewed for ADL care which resulted in unmet care needs.Findings include:Resident #5 (R5)Review of the Minimum Data Set (MDS) assessment for R5, dated 5/13/25, revealed admission to the facility on 2/13/25. R5 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. Section GG revealed R5 requires partial to moderate assistance for showers/bathing and set up or clean-up assistance for shaving.During an observation and interview on 7/22/25 at 1:40 p.m., R5 was sitting in a recliner in his room. R5 had long facial whiskers and disheveled hair. R5 stated, I haven't had a shower in two weeks, and no one will help me.I can't do it myself and would like to be shaved.My facial hair itches me.I would like to have a haircut too.On 7/23/25 at 9:30 a.m., R5 was observed sitting in his recliner in his room, still unshaved.On 7/23/25 at 9:30 a.m.,…

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 provide oxygen services including humidification and routinely changing oxygen tubing for one Resident (#11) of two residents reviewed for oxygen services. This deficient practice resulted in discomfort and unmet care needs.Findings include:Resident #11 (R11)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/23/22, with active diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and respiratory failure. R11 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.During an observation on 7/22/25 at 1:20 p.m., R11 received oxygen via nasal cannula with an empty bottle of humidification solution attached to the oxygen concentrator and the label on the oxygen tubing was dated 6/30/25. During an interview at the time of this…

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 maintain a medication administration error rate less than 5% in two Residents (#2 & #7) of three residents reviewed for medication administration, resulting in 2 medication errors in 26 opportunities for error and a 7.69% medication error rate.Findings include:Resident #2 (R2)On 7/24/25 at 9:01 a.m., Registered Nurse (RN) J was observed preparing an insulin pen for R2. RN J primed the pen holding it horizontally, with he needle cover on the pen. RN J did not observe the pen to ensure that insulin was primed into the pen needle, nor did he reprime to ensure it was done correctly. Review of the INSTRUCTIONS FOR USE, Insulin Lispro KwikPen, copyright 2023, retrieved from pi.[NAME].com/insulin-lispro-kwikpen-us-ifu-pdf on 7/24/25 at 9:51 a.m. revealed the following, in part: . Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air…

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 the resident representative understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for two Residents (Resident #8 and Resident #31) of three residents reviewed for arbitration.Findings include:Resident #8 (R8)Review of R8's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/12/22, with active diagnoses that included: Alzheimer's Disease, Non-Alzheimer's dementia, and anxiety disorder.During an interview on 7/25/25 at 9:10 a.m., Social Worker A reported R8 signed the arbitration agreement on 1/9/25. Social Worker A reported R8 had a responsible party (an individual designated to oversee various aspects of a resident's care and well-being) put in place which began on 1/17/25. Social Worker A acknowledged she did not review the arbitration agreement with the responsible party.Resident #31 (R31)Review of R31's MDS assessment dated [DATE], revealed admission…

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 the call light communication system was fully operational for 6 Residents (#1, #2, #6, #9, #10, & #11), out of the total population of 46 residents residing in the facility. This deficient practice resulted in residents' inability to utilize the call light system for emergency care needs, delayed provision of care and resident dissatisfaction. Findings include: This deficiency pertains to Intakes MI00146426 & MI00147954 which both alleged the facility call lights were not operational. Resident #2 (R2) Review of Intake MI00147954 revealed; Complainant (F) states the resident call light also wasn't working (on 10/1/24) . between 10/7/24 and 10/11/24 the resident's (R2's) call light still wasn't working . during a visit with the resident [Complainant F] pressed [R2's] call button because they needed to have a bowel movement and needed help getting to the bathroom. The complainant states no one was responding so [Complainant F] went…

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 information regarding facility rules and regulations, including denture loss, prior to or upon admission to the facility for one Resident (R2) of three residents reviewed for notice of rights and rules. Findings include: This deficiency pertains to Intake MI00147954. Review of the Complaint Intake MI00147954 on 12/3/24 revealed the following, in part: .During the late afternoon on 9/29/2024 [Complainant F] cleaned the residents top and bottom dentures per his request and put them back in their case on his bedside table. The complainant states on 9/30/24 [they] received a call from the facility staff asking if [they] took the residents (R2's) dentures home . because they were missing. The complainant states [they] went to the facility at 5:00 p.m., and an aide [Certified Nurse Aide E] told [Complainant F] that [CNA E] saw the dentures on the nightstand the following evening and when he went into the room in the morning, they were missing . the residents' dentures still haven't been found . During a telephone…

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 respond timely to a change in condition for one Resident (R2) of three Residents reviewed for a change in condition. This deficient practice resulted in delayed transfer and treatment of an identified changed in condition. Findings include: This deficiency pertains to Intake MI00147954. Review of the Complaint Intake MI00147954 revealed the following, in part: .Complainant (F) . on 10/11/24 visited the resident (R2) and noticed his eyes were closed, but [R2] was flailing their arms and legs and appeared to be in pain . [Complainant F] alerted nursing staff and was told it was part of [R2's] decline and nothing to worry about . [Complainant F] visited the resident again on 10/12/24 and [R2] was in worse condition . [Complainant F] found [Registered Nurse (RN) B] and told [RN B] that they wanted the resident sent to the hospital. The Complainant states [RN B] said they needed to finish what they was doing and then they'd call the doctor. The complainant…

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 appropriately assess weights to assist in identification and prevention of significant weight loss for three Residents (R2 , R4, & R8), of six residents reviewed for weight management. This deficient practice resulted in inadequate weight documentation/tracking and the development of a significant weight loss for R2. Findings include: This deficiency pertains to Intake MI00147954. Review of R2's Minimum Data Set (MDS) assessment, dated 10/3/24, revealed R2 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: heart failure, urinary tract infection, acute pyelonephritis, and metabolic encephalopathy. R2 scored 4 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of the 10/13/24 Hospital Progress Note , revealed the following, in part: . Assessment/Plan: Malnutrition/Cachexia (wasting away appearance): Documented 30-pound weight loss (significant weight…

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 provide a safe, clean, homelike environment for all facility residents. This deficient practice resulted in the potential for injury and dissatisfaction with the living environment. Findings include: During the initial screening of residents on 8/5/24 at approximately 12:30 p.m., the facility carpet in all hallways was observed stained, bleached in color, and with separated carpet tile seams. The carpeting had many brown, orange, and other stains that appeared to be uncleanable. Resident #15's (R15's) room was observed on 8/7/24 at 8:23 a.m., accompanied by Registered Nurse (RN) P, which showed the presence of a large gap (area for potential entrapment) at the foot of R15's bed. RN P estimated the gap between the bed mattress and the bed footboard was between five to six inches. The bed footboard had a strip of peeling, vinyl laminate, hanging from the footboard. The radiator covers on the heating unit directly under the right edge 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 interview and record review, the facility failed to ensure two Certified Nurse Aides (CNA) [ L & N] had yearly competency training, including demonstration in skills and techniques necessary to care for the facility population. Findings include: During an interview on 8/7/24 at 11:39 a.m., the Director of Nursing (DON) stated, competency training is completed upon hire and annually, but I can't recall when last competencies were completed. The DON referred this surveyor to Human Resources/Business Office Manager H. During an interview on 8/7/24 at 11:47 a.m., the Human Resources/Business Office Manager H stated I do not have staff competencies. During an interview on 8/7/24 at 12:12 p.m., the DON stated, competencies are completed in May or June, but I do not know where they are. During an interview on 8/7/24 at 12:39 p.m., the Human Resource/Business Office Manager H stated, we are trying to find the competencies . I just don't have anything for you. During an interview on 8/12/24 at 1:03 p.m., the Nursing Home Administrator (NHA) stated, we do not have a policy 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 complete a performance review for five of five Certified Nurse Aides (CNA's) [F, L, M, N, & O] at least once every 12 months. Findings include: Review of facility personnel records revealed the following: CNA F was hired on 11/30/22 with no performance review. CNA L was hired on 11/21/22 with no performance review. CNA M was hired on 4/12/16 with no performance review. CNA N was hired on 10/26/22 with no performance review. CNA O was hired on 3/14/23 with no performance review. During an interview on 8/7/24 at 11:47 a.m., the Human Resource/Business Office Manager H stated, I don't have the staff evaluations. During an interview on 8/7/24 at 12:39 p.m., the Human Resource/Business Office Manager H stated, we are trying to find them .I don't have anything to give you. During an interview on 8/12/24 at 1:03 p.m., the Nursing Home Administrator (NHA) stated, we do not have a policy on performance reviews for staff.

Based on interview and record review, the facility failed to enter the census (total number of residents) on the facility staffing information posting used to calculate appropriate levels of staffing. This deficient practice resulted in the potential for inaccurate staffing levels. Findings include: A review of the direct care staffing hours (Nursing Department Daily Staffing sheets) on 8/7/24 revealed no resident census information on 1/6/24, 1/7/24, 1/13/24, 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/10/24, 2/11/24, 2/17/24, 2/18/24, 2/24/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10,24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, and 3/31/24. During an interview on 8/7/24 at 10:09 a.m., the Nursing Home Administrator (NHA) acknowledged the resident census information was not posted on the Nursing Department Daily Staffing sheets. The NHA stated, the sheets should have the census on those sheets .she didn't fill those out right. Review of facility policy titled Nurse Staffing Posting Information last revised dated 3/24 . read in part, the nurse staffing…

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 store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: - Failing to ensure expired food was discarded. - Failing to maintain three freezers in a sanitary condition. - Failing to ensure the dietary ice machine was cleaned in a manner which prevented potential contamination of ice used by residents. - Failing to ensure the facility dishwasher properly sanitized all items. This deficient practice had the potential to result in food borne illness among any or all 46 residents in the facility who receive meals. Findings include: On 8/5/24 at 12:15 PM, an initial tour of the kitchen was made with Dietary Manager (Staff) B. There was a gallon container of fruit salad in the walk-in refrigerator dated as opened 7/17/24 and a use by date of 7/22/24. Staff B stated she would throw this out as it had expired. The walk-in refrigerator also contained an unlabeled undated gallon jug of juice which Staff B identified as cranberry juice. Staff B stated this should be…

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 complete a comprehensive facility assessment that included training that resulted in the potential for unidentified resources necessary to provide care and services to the resident population. Findings include: During an interview on 8/7/24 at 11:39 a.m., with the Director of Nursing (DON) revealed the competency /training list did not include training on ethics, communication, resident rights, infection control, abuse and neglect, or Quality Assurance Performance Improvement (QAPI). The DON was queried about the Facility Assessment to include training. The DON stated, staff receive education on [Facility Continuing Education Provider] and I am unaware of the training required on facility assessment. During an interview on 8/12/24 at 1:12 p.m., the Nursing Home Administrator (NHA) was queried regarding training for staff and if it would be in the Facility Assessment the NHA stated, I don't know about the trainings you brought up (QAPI, infection control, communication, resident rights, abuse, compliance, ethics, 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 on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 45 residents. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Excessively Low Weekend Staffing Triggered with Submitted Weekend Staffing is excessively low with infraction dates being : 1/6/24, 1/7/24, 1/13/24, 1/14,24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/10/24, 2/11/24, 2/17/24, 2/18/24, 2/24/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10,24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, and 3/31/24. During an interview on 8/7/24 at 10:10 a.m., the Nursing Home Administrator (NHA) stated, I do not know what happened with the PBJ information, it probably wasn't entered right. Review of facility policy titled Payroll Based Journal last revised dated 6/24 . read in part, it is the policy of this facility to electronically…

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 implement, monitor, and document the antibiotic stewardship program. This deficient practice has the potential to affect all residents with exposure to unnecessary medications, antibiotic resistance, and infection. Findings include: During an interview on 8/7/24 at 12:58 p.m., the Director of Nursing/Infection Preventionist (DON/IP) stated, I do not have a current listing for antibiotic stewardship from June or July, I have not been tracing or monitoring the use of antibiotics. During an interview on 8/8/24 at 9:32 a.m., this surveyor queried the DON/IP to review the antibiotic stewardship binder for the past 3 months. The DON/IP stated, I have nothing written for antibiotics on a line listing . I haven't done any of it .we get a report from the pharmacy and look at that. During an interview on 8/8/24 at approximately 11:00 a.m., this surveyor queried the DON/IP to review a resident who received antibiotics. The DON/IP stated, I have not tracked anyone who has received antibiotics, I have nothing to show you regarding…

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 educate and offer COVID-19 vaccination for staff resulting in increased risk for COVID-19 infections and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings include: During an interview on 8/7/24 at 3:05 p.m., the Director of Nursing (DON) stated, there has not been any education about COVID-19 for staff or COVID-19 vaccine offered to staff. During an interview on 8/12/24 at 1:08 p.m., the Nursing Home Administrator (NHA) stated, we used to educate and offer education and the COVID-19 vaccine . it has not been offered .and not offered every month. During an interview on 8/12/24 at 2:34 p.m., Registered Nurse (RN) S stated, I have not been educated about COVID-19 or offered the COVID-19 vaccine the last almost two years that I have worked at this facility. Review of facility policy titled Employee Vaccinations last revised 10/23 . read in part, 1. vaccination offerings: [Facility] will provide . COVID-19 vaccinations .all healthcare providers (HCP) will be offered the COVID-19…

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 conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of potential entrapment for all facility residents. This deficient practice resulted in the potential for risk of injury to all 47 vulnerable facility residents. Findings include: Observation of Resident R15's room on 8/7/24 at 8:23 a.m., accompanied by Registered Nurse (RN) P, showed the presence of a large gap (area for potential entrapment) at the foot of R15's bed. RN P estimated the gap between the bed mattress and the bed footboard to be between five to six inches. During an observation and interview on 8/7/24 at approximately 1:20 p.m., Staff Q was asked for a tape measure. Staff Q measured the gap between the end of R15's mattress and the footboard on the bed. Staff Q said the gap between the footboard and the mattress was between 5 and 5.5 inches, which he acknowledged was outside of the acceptable measurement of 4 inches to prevent resident entrapment. During an interview on 8/8/24 at 2:42 p.m., Maintenance…

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 conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of potential entrapment for all facility residents. This deficient practice resulted in the potential for zones of entrapment to remain unidentified posing a risk to all 45 vulnerable facility residents. Findings include: Observation of the room for Resident #15 (R15) on 8/7/24 at 8:23 a.m., accompanied by Registered Nurse (RN) P, revealed the presence of a large gap (area for potential entrapment) at the foot of R15's bed. RN P estimated the gap between the bed mattress and the bed footboard to be between five to six inches. During an observation and interview on 8/7/24 at approximately 1:20 p.m., Staff Q was asked for a tape measure. Staff Q measured the gap between the end of R15's mattress and the footboard on the bed. Staff Q said the gap between the footboard and the mattress was between 5 and 5.5 inches, which he acknowledged was outside of the acceptable measurement of 4 inches to prevent resident entrapment.…

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 (R2) received food in the appropriate form as prescribed by a physician and - failed to ensure the appropriate nutritive content was served to 46 residents receiving meals from the dietary department. Findings include: During the lunch meal service on 8/6/24 at 12:03 PM, the dietary tray line was observed. The menu consisted of turkey casserole and corn. The turkey casserole contained diced turkey meat approximately ½ inch wide, ½ inch deep and in varying lengths from ¾ inch to 1 1/2 inches . The Dietary Manager (Staff) B explained the casserole was substituted for fried chicken, which had not come in on the delivery truck. Staff B stated there were two residents who required mechanically altered food. Staff B said she did not grind the turkey but tried not to give (R2) any chunks. The tray card for R2 was reviewed and read in part, Diet order: 5-Minced and moist. *General . Alerts: All food chopped. 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 provide written transfer notification to the resident and resident's representative for one Resident (R45) of two residents reviewed for transfers out of the facility. Findings include: Resident #45 (R45) On 8/4/24, R45 was transferred to the hospital with nausea/vomiting and uncontrolled pain. During an interview on 8/7/24 at 5:20 PM, the Regional Clinical Consultant Registered Nurse A stated the facility did not send written notifications to the resident or resident representatives and she had never heard of this. During an interview on 8/8/24 at 12:18 PM, the Nursing Home Administrator said they did complete a transfer form but it was not given or mailed to the resident or resident representative.

Based on observation, interview, and record review, the facility failed to provide wound care per comprehensive care plan, per physician orders and without proper infection control practices for one Resident (R47) out of 12 sample residents. This deficient practice resulted in the potential for delayed wound healing and potential for infection. Findings include: Review of the Minimum Data Set (MDS) assessment for R47, dated 7/25/24, revealed admission to the facility on 4/18/24 following a short-term hospital stay. R47 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R47 had unclear speech and was usually able to be understood and understand others. Active diagnoses upon admission included the following, in part: stroke, aphasia, hemiplegia (paralysis of one side of the body). R47 required Supervision or touching assistance, where the helper provided verbal cues and/or touching/steadying and/or contact guard assistance as the Resident rolled from side to side. Review of R47's Physician Order Summary, retrieved 8/5/24, revealed 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 interview and record review, the facility failed to provide adequate supervision to prevent a fall for one Resident (R50) of two residents reviewed for falls. This deficient practice resulted in a fall with injury (fractured hip), and a decline in condition. Findings include: Review of the facility Investigation Summary revealed the following, in part: .R50 suffered a right hip fracture after an unwitnessed fall that occurred on [DATE] at approximately 8:15 PM. RN (Registered Nurse) caring for resident responded immediately after receiving a phone call at the nurse's station from [R50's] roommate .Resident was then transferred to [Acute Care Hospital] for imaging, d/t (due to) complaints of right hip pain . Resident was non-compliant with using her call light when needing assistance with ambulation while admitted to [Facility Name] . The Investigation Summary documented R50 scored 3 of 15 on the Brief Interview for Mental Status (BIMS), reflective of severe cognitive impairment, and diagnoses that…

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 the provision of training on resident rights training for two of five staff reviewed for resident right training. This deficient practice had the potential of facility staff violating the rights of all 45 residents in the facility. Findings include: Review of [Vendor] Computer training logs on 8/7/24 at approximately 4:00 p.m., revealed the following staff had no resident rights training: Certified Nurse Aide (CNA) L was hired on 11/21/22 and CNA N was hired on 10/26/22 Review of Facility Assessment (FA) did not include a requirement for the provision of resident rights training for staff. Review of facility policy titled Resident Rights last revised .dated 2/24, read in part the facility will ensure that all direct care and indirect care staff members .are educated on the rights of residents.

Based on interview and record review, the facility failed to ensure the provision of training on Quality Assurance Performance Improvement (QAPI) training for one L of five staff reviewed for QAPI training. This deficient practice had the potential to result in unmet care needs due to an ineffective performance improvement program. Findings include: Review of [Vendor] Computer training logs on 8/7/24 at approximately 4:00 p.m., revealed the following staff had no QAPI training: Certified Nurse Aide (CNA) L was hired on 11/21/22. Review of Facility Assessment (FA) did not include a requirement for the provision of QAPI training for staff. Request for QAPI policy from this Surveyor. Facility did not provide QAPI policy prior to exit from facility on 8/12/24

Based on interview and record review, the facility failed to ensure the provision of training on infection control for one of five staff reviewed for infection control training. This deficient practice had the potential for the spread of diseases and infectious processes to all 45 residents in the facility. Findings include: Review of [Vendor] Computer training logs on 8/7/24 at approximately 4:00 p.m., revealed the following staff had no infection control training: Certified Nurse Aide (CNA) O was hired on 3/14/23. Review of Facility Assessment (FA) did not include a requirement for the provision of infection control training for staff. Review of facility policy titled Infection Prevention and Control Program last revised .dated 12/19, read in part . all staff shall receive training .regarding the facility's infection prevention and control program.

Based on interview and record review, the facility failed to ensure nurse aide training of no less than 12 hours per year for two Certified Nursing Assistants (CNA) L and N of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 45 residents in the facility. Findings include: During an interview on 8/7/24 at 11:47 a.m. Human Resource/Business office Manager H revealed the 12 hours of annual CNA training is based on the CNA's hire date. On 8/7/24 at approximately 12:30 p.m., a review of CNA L training log revealed L was hired on 11/21/22 and had only 10 hours of in-service training. A review of CNA N training log revealed that N was hired on 10/26/22 and had only 11.75 hours of in-service training. During an interview on 8/12/24 at 1:12 p.m., the Nursing Home Administrator (NHA) stated, there is no way we can communicate to the staff about completing any trainings or what they have to do for training .it is on the [Vendor] training and that is what we do for training. Review of facility policy…

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 provide a 30-day written notice of discharge with notification to the Office of the State Long-Term Care Ombudsman and the State Agency for one Resident (R1) of three residents reviewed for notice before discharge. This deficient practice resulted in an inappropriate discharge from the facility without notification of discharge and appeal rights to the Resident and/or Resident's Representatives. Findings include: This deficiency pertains to Complaint Intake #MI00143858. Review of R1's Minimum Data Set (MDS) Annual assessment, dated (in process) 4/6/24, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included: stroke, heart failure, end-stage renal disease, neurogenic bladder (with surgical placement of a suprapubic catheter), diabetes mellitus, Non-Alzheimer's dementia, depression, antisocial personality disorder, chronic obstructive pulmonary disease, hemiplegia (paralysis of one side of the body), morbid obesity, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically related social services pertaining to discharge for one Resident (R1) of three residents reviewed for discharges. This deficient practice resulted in an inappropriate involuntary discharge, failure to inform the Resident and/or Resident Representative of their involuntary discharge appeal rights, and emotional distress based on a reasonable person standard. Findings include: This deficiency pertains to Complaint Intake #MI00143858 which alleged the facility failed to complete and thorough discharge plan for R1 .There is concern that [Nursing Home Name] performed an unsafe and unprepared discharge that has now placed [R1] at risk of harm due to having no services and no proper caretaker . Review of R1's Minimum Data Set (MDS) Annual assessment, dated (in process) 4/6/24, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included: stroke, heart failure, end-stage renal disease, neurogenic bladder (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Linked intake MI00142531 Based on interview and record review, the facility failed to report timely an allegation of misappropriation of resident property (narcotics) to the State Agency (SA) for one Resident (R4) of four residents reviewed for abuse reporting. Findings include: Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including neurocognitive disorder with lewy Bodies, reduced mobility, and muscle weakness. R4's 12/8/23 Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score but was not marked for her cognitive status. Further review showed R4 had not received any scheduled or as needed (PRN) pain medications in the last five days of this review. Review of R4's 3/9/24 MDS assessment revealed she scored a 15/15 on the BIMS score, indicative of R4 being cognitively intact. On 4/2/24 at approximately 10:00 a.m., The Nursing Home Administrator (NHA) and Director of Nursing (DON) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Linked intake MI00142531 Based on interview and record review, the facility failed to conduct a thorough investigation for a misappropriation of resident property (narcotic medication) for one Resident (R4) of four residents reviewed for abuse. This deficient practice resulted in undetected abuse and/or misappropriation and the potential for unmet care needs: Findings include: Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy Bodies, reduced mobility, and muscle weakness. R4's 12/8/23 Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score but was not marked for her cognitive status. Further review showed R4 had not received any scheduled or as needed (PRN) pain medications in the last five days of this review. Review of R4's 3/9/24 MDS assessment revealed she scored a 15/15 on the BIMS score, indicative of R4 being cognitively intact. 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.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failing to hold food at proper temperature being stored in a walk in cooler. These deficient practices have the potential to result in food borne illness among any and all 53 residents of the facility. Findings include: On 7/11/23 between approximately 7:30 AM and 9:45 AM, initial tour observations were conducted of the kitchen. The walk in cooler (WIC) unit was observed to be recording an ambient air temperature of 47°F, as indicated on the external digital thermometer next to the door. A thermometer on the interior of the WIC and confirmed and matched the 47°F temperature reading of the external digital. Temperatures were measured on potentially hazardous food products which were identified by [NAME] B as having been in the WIC cooler overnight. This was conducted to demonstrate any differences between the current ambient air and food product temperature in the unit. A gallon of milk,…

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 intake # MI00131776 This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak. This deficient practice placed all residents residing in the facility at risk for the potential of the development and spread of disease and infection and the potential for an outbreak to go undetected. Findings: During an interview on 07/13/23 at 10:54 AM, Director of Nursing (DON) reported that she had taken over the Infection Control Program in June of 2023 from the previous DON. DON reported that the previous DON had not been tracking staff illnesses and had not been completing the line listing for staff illness outside of COVID-19 illnesses/symptoms. DON reported that tracking staff illness is a high priority in order to keep the residents safe and prevent an outbreak. DON reported that since she took over the Infection Control…

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 observations and interview, the facility failed to provide an environment which was safe, sanitary and functional for residents, staff and visitors, as evidenced by compressed gas cylinders being unrestrained, corridor hand rails which were missing or in conditions to cause injury, and allowing a potential cross connection between the potable water supply and garbage disposal drain in the kitchen. These deficient practices have the potential to result in injury or illness to all 63 residents in the facility. Findings include: On 7/11/23 at 8:05 AM, again at 8:45 AM, 1:30 PM, then on 7/12/23 at 8:30 AM, a cylinder of compressed oxygen was observed inside the door of the clean laundry room, adjacent to the laundry services room. The tank was free standing approximately 30 from the wall and among other cylinders which were restrained from falling over. The failure to restrain compressed gas cylinders has the potential to result in the tank falling over, severing the regulator on top and creating 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 Resident #28 (R28) Review of an admission Record reflected R28 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, weakness, urine retention, dementia without psychotic disturbance, mood disturbance or anxiety and abnormalities of gait and mobility. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and was independent with locomotion on the unit. Resident #25 (R25) Review of an admission Record reflected R25 admitted to the facility with diagnoses that included anxiety, a personal history of traumatic brain injury, adjustment disorder, contracture of the right hand, post-traumatic seizures and abnormalities of gait and mobility. Review of a quarterly MDS assessment dated [DATE] reflected R25 was cognitively intact as evidenced by a BIMS score of 12/15 and required limited assistance from 1 person for locomotion on the unit. Review of a Facility…

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 Resident #1 (R1) Review of an admission Record reflected R1 admitted to the facility with diagnoses that included Type 2 Diabetes with foot ulcer, morbid (severe) obesity, bipolar disorder, dysphagia, obstructive sleep apnea, muscle weakness, borderline personality disorder, major depressive disorder, generalized anxiety disorder and gastroparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R1 needed extensive assistance from two people for bed mobility, transfers and toilet use and needed extensive assistance from one person for dressing. Review of a Facility Reported Incident (FRI) reflected that on 12/4/23 at approximately 4:00 AM, Licensed Practical Nurse (LPN) O was witnessed by Certified Nurse Aide (CNA) P and an alert and oriented resident yelling at R1 and telling her to go to her room for smacking her lips. R1 reported the interaction to LPN R and the incident was…

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 This citation pertains to intake MI00131776 Based on interview and record review, the facility failed to honor resident preferences for customary routines and activities for 3 residents (Residents #1, #30 and #48) resulting in depersonalization and diminished quality of life. Resident #1 (R1) Review of an admission Record reflected R1 admitted to the facility with diagnoses that included Type 2 Diabetes with foot ulcer, morbid (severe) obesity, bipolar disorder, dysphagia, obstructive sleep apnea, muscle weakness, borderline personality disorder, major depressive disorder, generalized anxiety disorder and gastroparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R1 needed extensive assistance from two people for bed mobility, transfers and toilet use and needed extensive assistance from one person for dressing. The assessment also revealed R1 was sometimes incontinent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide quality care to two resident's (Resident #31 and Resident #36) by (a) not administering pain medications, (b) not documenting neurological assessments completely, (c) not tracking behaviors, (d) not re-assessing the need for high doses of antipsychotic medications, (e) not checking vital signs on a daily basis as required by documentation, (f) not monitoring lab values when administering supplements, and (g) not notifying the physician when a medication was unavailable for greater than 2 days, resulting in the resident's not functioning at the highest possible functional level of well-being. Findings: Resident #31(R31) Review of an admission Record revealed R31 was an [AGE] year-old female, admitted to the facility on [DATE], following multiple falls at home that resulted in two lumbar vertebral fractures and a broken rib. R31 had pertinent diagnoses of Dementia, COPD (chronic obstructive pulmonary disease), high blood pressure,…

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 adequate monitoring, assessment and care for 1 resident (Resident #3) with an indwelling catheter, reviewed for urinary catheter/UTI (urinary tract infection) care, resulting in the increased potential for infection and urinary complications. Findings include: Resident #3 (R3) Review of an admission Record revealed R3 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: retention of urine. Review of R3's Physician Order revealed, Monitor residents Foley catheter for SS (signs and symptoms) of UTI (urinary tract infection), monitor vitals and temp. Report to PCP (primary care provider) any changes. Ok to flush per standing order. every shift Monitor for SS of UTI Start Date 10/05/2022. Monitoring for other types of infection, obstruction, securement, and compromise of the closed system was not included. Review of R3's Physician Order revealed, Maintain 16 FR/ 10 ML foley catheter to straight…

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.