Mission Point Nursing & Physical Rehab Center Of L

Based on observation, interview, and record review, the facility failed to implement its Infection Control and Prevention policies and procedures during resident care and medication administration and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: During an observation of medication administration beginning at 8:15 AM on 12/15/2025, Registered Nurse (RN) D was met at the medication cart on the east hall of the facility. An uncovered plastic cup of yellow carbonated liquid was observed to the right of the computer. An uncovered cup of clear liquid was observed to the left of the computer screen. When asked, RN D said the yellow liquid was their personal drink and that the other uncovered cup of clear liquid was water she had poured for another resident who was not yet ready for their medications. During an observation of medication administration on 12/15/2025 at 8:30 AM, RN D…

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 and interview, the facility failed to maintain general cleanliness and repair of staff access only areas and residents living areas. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, among all the residents in the facility.Findings include: On 12/14/2025 at 10:58 AM, observed, in the Resident Care Supply room, the condenser cover of ice machine had a buildup of debris on the surface. On 12/15/2025 at 8:25AM, walkthrough of building with Environmental Manager (EM) L, during discussion regarding cleaning schedule EM L stated that their TELLs system automatically reminds his department of continuous cleaning and maintenance schedules, ice machine is scheduled to be wiped down monthly by housekeeping personnel. On 12/14/2025 at 11:01AM, observation of hopper in the Soiled Utility room on East Hall, the hopper had a buildup of brown film on the interior, the film was partially dislodged when sprayed with water. On 12/15/2025 EM L…

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 was within reach for one (Resident #10) of seven resident's reviewed for call light placement. Findings:Resident #10 (R10)Review of an admission Record revealed R10 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of anoxic (lack of oxygen) brain damage, unsteadiness on feet, muscle weakness, and adjustment disorder with anxiety. R10 required assistance from 1 staff person for most ADL's (activities of daily living).During an observation on 12/14/25 at 9:36 AM, R10 sat up in bed awake and stated that he did not know where his call light was. The call light laid on top of the heat vent, almost to the floor, between the wall and the resident's bed out of sight and out of reach. During an observation on 12/14/25 at 11:40 AM, the floor nurse went into R10's room and brought in his medications. After the nurse finished and exited R10's room, the call light remained on 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 licensed nurses followed The Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time) of medication administration in accordance with professional standards for 2 residents (R8 and R27) out of 3 residents observed during medication administration. Findings Include: During an observation on 12/15/2025 at 8:20 AM, Registered Nurse (RN) D prepared medications for R8 including Lidocaine External Patch 4% (Lidocaine) and Cranberry Oral Tablet 500 MG (milligram) (Cranberry (Vaccinium macrocarpon)) Give 2 tablets by mouth in the morning for UTI (urinary tract infection) prevention. RN D discovered the only dosage form of the Cranberry supplement prescribed for R8 available in the facility was a 450 MG tablet, not the 500 MG dosage ordered. RN D reported she would obtain a clarification order from the prescriber before administering a dose lower than prescribed. During the same medication administration observation on 12/15/2025 at 8:30 AM, RN D discovered a Lidocaine patch was already…

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 and interview, the facility failed to maintain cleanliness and general repair of equipment, plumbing, the onsite waste water system, and other aspects of the physical environment. This deficient practice has the potential to affect all residents in the facility. Findings Include: During a tour of the dry storage room, at 10:22 AM on 10/21/24, it was found that an odor resembling sewer gas was present upon entering the room. When asked if they knew what the odor was, Dietary Manager R and Regional Dietitian U were unsure. Upon further evaluation of the room, it was found that a slowly leaking sewer pipe was observed in the back left corner with totes underneath it to catch the leak. The sewer pipes were observed covered in duct and electrical tape in some spots, with no adequate fix to the line. No food storage was under this area. During a tour of the facility, at 1:40 PM on 10/21/24, observation of the Ice Machine room with Regional Dietitian U, found a black rubber insulated seal 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 Based on observation, interview, and record review, the facility failed to position a urinary catheter collection bag to facilitate drainage for 1 resident (Resident #20) of 2 residents reviewed for urinary catheter care. Findings include: Review of an admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] with pertinent diagnoses which included flaccid neuropathic bladder and retention of urine. Review of a Minimum Data Set (MDS) assessment for R20, with a reference date of 10/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R20 was cognitively intact. Review of a current urinary catheter Care Plan intervention for R20, initiated 4/16/2024, directed staff to position her urinary catheter bag below the level of the bladder. In an observation and interview on 10/21/2024 at 3:28 PM in R20's room, R20 was sitting in her wheelchair with her urinary catheter collection bag hanging from the back of her wheelchair…

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 date and discard an outdated-for-use biological medication and failed to discard two insulin pens kept in active storage past the manufacturer's recommended expiration date and after the medication had been discontinued. Findings: On [DATE] at 7:55 AM a review was conducted of the facility medication room with Licensed Practical Nurse (LPN) J. Review of the medication refrigerator revealed an opened and entered multidose vial of purified protein derivative (PPD) solution. It was observed that the vial was not dated when it had been placed in service. LPN J noted that the box in which the undated vial was contained was dated [DATE] but that the vial itself was not dated. LPN J indicated she did not know the date the vial had been placed into service and reported that the vial expiration date would be the manufacturer's expiration date on the vial. On [DATE] at 8:10 AM the North unit medication cart was reviewed with Registered Nurse (RN)…

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 proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions (EBP) for 1 resident (Resident #22) of 12 residents reviewed for infection control. Findings include: Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcers. Review of R22's Physician's Orders, active 10/23/2024 at 9:00 AM, revealed he required multiple daily dressing changes. Further review revealed no order for EBP's. In an observation and interview on 10/23/2024 at 9:30 AM in R22's room, Registered Nurse (RN) E performed several dressing changes without donning a gown. There was no signage on the door indicating the need for PPE. RN E reported R22 should have EBP's in place because of his wounds. In an interview on 10/23/2024 at 10:04 AM, the Director of Nursing (DON) reported R22 should have had EBP's in place since admitting to the 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 This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively implement interventions for effective communication for one resident (R2) of four reviewed for care plans, resulting in the miscommunication of care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported that R2 cannot speak or say words like that because she has expressive aphasia. He works with her every day using word cards and a computer program to encourage her to speak in the mornings. He said the facility staff does not know how to communicate with her like he does. In an interview on 7/24/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00145786 Based on observation, interview, and record review, the facility failed to effectively manage care for one resident (R2) of four reviewed for quality of care, resulting in unmet care needs. Findings include: Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE] with pertinent diagnosis of hemiplegia and hemiparesis (one sided weakness), aphasia (may be unable to comprehend or unable to formulate language because of damage to specific brain regions), and cognitive communication deficit. In an interview on 7/24/24 at 8:28 AM, the Designated Power of Attorney (DPOA)/husband of R2 reported he saw her Friday morning on 7/19/24 and she was timid and didn't want to communicate which was abnormal for her, because she is usually cheery. He left and came back in the afternoon and R2 was having some pain in her abdominal/vaginal area. He had the nurse assess R2 and did not see any concerns. The next morning on 7/20/24, the DPOA came to visit,…

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: 1. Ensure sufficient hot water at the hand sink; 2. Properly datemark food product; 3. Properly store food product; and 4. Ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 30 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:05 AM on 1/8/24, it was observed that the hand sink, located to the right of the dish machine, was not providing hot water to achieve the required 100F. At this time, the hot water was checked with a rapid read digital thermometer and found to only reach 61F. An interview with Dietary Aide F found that the hand sink never seems to get hot, but the one compartment wash sink (next to the hand sink on the dish machine line) gets hot. Further observation found that the hot water line under the hand sink passes through a mixing valve. According to the 2017 FDA Food Code section 5-202.12…

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 a dignified dining experience for four residents who required assistance to be fed (Resident #10, Resident #14, Resident #18, and Resident #26), of 4 residents reviewed, resulting in staff standing over the residents to assist with feeding in an undignified manner and providing intermittent feeding assistance with the potential for the residents' food to get cold. Findings include: Resident #10 (R10) Review of the Care Plan for R10 revealed she has dysphagia with a general diet with 4-pureed textured foods, thin liquids and is allowed a regular texture meal when alert. Her independence with meals fluctuates and is to be provided assistance as needed. She does better with finger foods at meals, initiated 4/29/19. She is also care planned for being dependent for feeding initiated 2/3/22. Resident #14 (R14) Review of the Care Plan for R14 revealed she is dependent for eating, initiated on 1/27/21. The feeding techniques she requires is to be fed by staff, she has a history of pocketing food, initiated…

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 stored and administered according to professional standards, resulting in the potential for significant medication errors and clinically adverse consequences. Findings include: Review of the Medication Administration policy dated June 2019 revealed, B. Administration: 3. Medications are administered at the time they are prepared. Medications are not pre-poured in advance of the medication pass or for more than one resident at a time. During an observation and an interview on 1/10/24 at 9:35 AM, Licensed Practical Nurse (LPN) I had two medication cups with medications in them for two different residents in her hand. LPN I reported the one resident was not ready for his medications yet, so she put his name on the cup and placed it back into the locked medication cart and proceeded to the other resident's room to administer his medications. This surveyor told her when she was done with that medication pass, the next medication pass will need to be observed from the beginning. When LPN I…

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 adequate nursing staffing to provide 1 Resident (R202) with care as needed, resulting in R202 sitting in urine past the standard 2-hour check and change and experiencing discomfort and potential for skin breakdown. Findings include: Review of R202's face sheet dated 9/28/23 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: Schizoaffective disorder, epilepsy, chronic pain, anoxic brain damage (loss oxygen causing brain damage), aphasia (loss of the ability to understand or express speech caused by brain damage), bipolar disorder, anxiety disorder and muscle weakness, R202 was not her own responsible party and was currently in hospice care. On 9/28/23 at 12:35 PM R202 was up in her chair at the Nurse's Station and Registered Nurse (RN) E was feeding her ice cream. R202 was asked if she liked ice cream and she did not respond. R202 began sliding and lifting her buttock off…

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.