Addison Pointe Health & Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bruises were assessed and monitored for 2 of 3 residents reviewed for non-pressure related skin conditions, blood pressure medications were administered within parameters for 2 of 3 residents reviewed for medications with parameters, and an assessment was documented prior to and after an outpatient procedure for 1 of 3 residents reviewed for falls. (Residents 77, 48, 42, and 11)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were stored appropriately related to nystatin powder, insulin pens were not used past the expiration date, and over the counter medications were labeled correctly for 2 of 2 residents observed with medications in their rooms and for 2 of 4 medication carts observed. (Residents 42 and 9, the 100 hall and 400 hall medication carts)

Inspectors wroteBased on observation and interview, the facility failed to maintain a resident's dignity related to checking a resident's blood sugar and announcing the result in a common area for 1 of 2 residents reviewed for dignity. (Resident 97)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADLs) received the care and assistance needed related to trimming their fingernails for 2 of 7 residents reviewed for ADLs. (Residents 7 and 57)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents reviewed for activities. (Resident 22)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide oxygen at the correct flow rate and with protective padding as ordered for 1 of 1 resident reviewed for respiratory care. (Resident 22)

Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria (standardized definitions used for urinary tract infection (UTI) surveillance in long-term care, requiring both specific symptoms and microbiologic evidence) for 2 of 3 residents reviewed for urinary tract infections. (Residents 42 & 5)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, dependent on staff for transferring from the chair to bed, had received adequate assistance and supervision to prevent accidents related to staff not following the manufacture's manual regarding keeping the legs of the lift at their maximum opened position before lifting a resident during a mechanical lift transfer for 1 of 2 residents reviewed for accidents. (Resident 21) This deficient practice resulted in the resident falling and receiving a fracture to her left upper arm. The deficient practice was corrected on 10/16/24, prior to the start of the survey, and was therefore past noncompliance. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the kitchen in a sanitary manner and in good repair related to lack of monitoring of freezer, refrigerator, and dishwasher temperatures and food not labeled and dated, for 1 of 1 kitchen. This had the potential to affect 86 of 87 residents who resided in the facility and received food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement a resident's care plan related to positioning for 1 of 3 residents reviewed for limited range of motion (ROM). (Resident 33)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents, related to turning and repositioning for 1 of 2 residents reviewed for ADLs. (Resident 33)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of discoloration were assessed and monitored for 2 of 2 residents reviewed for non-pressure skin conditions .(Residents 62 and 44)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure reduction devices were in use for a resident with a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 66)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident requiring respiratory care received necessary services related to changing oxygen tubing for 1 of 4 residents reviewed for respiratory services. (Resident 44)

Inspectors wroteBased on observation, record review, and interview, the facility failed to file and resolve a resident grievance for a missing wheelchair for 1 of 1 resident reviewed for grievances. (Resident M)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for infection control isolation practices. (RN 1, CNA 1, and Resident E).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders to administer their own medications, as well as a self-administration of medication assessment, for 1 of 1 residents reviewed for self-administration of medication. (Resident 6)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, and treatment orders were obtained timely for a resident with a skin tear, for 2 of 2 residents reviewed for skin conditions non-pressure related. (Residents 66 and 79)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure finger orthotics were available and worn as ordered, for 1 of 1 residents reviewed for range of motion. (Resident 12)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 residents reviewed for dialysis. (Resident 199)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were complete and accurately documented, related to meal consumption, for 1 of 3 residents reviewed for nutrition. (Resident 46)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a dependent resident received timely ADL (activities of daily living) assistance needed related to incontinence care for 1 of 1 random observations. (Resident D)