Allison Pointe Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure resident documentation was complete and accurate for 1 of 4 residents reviewed for receipt of care and services (Resident B)

Inspectors wroteBased on interview and record review, the facility failed ensure a resident received timely foot care related to a referral for a vascular specialist and treatment for osteomyelitis, resulting in a hospitalization for intravenous antibiotics and subsequent toe removal for 1 of 3 residents reviewed for foot care. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served with proper hand hygiene, coffee was covered when transported in hallways, food trays were air dried prior to storage, and the kitchen environment was clean related to ceiling vents potentially affecting 102 of 109 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 7 of 31 rooms, 1 of 2 exit doors, and 1 of 2 Nurse's Stations reviewed for environment. Doorknobs were loose, urine odor was present, designated smoking area exit door frame was pulled away from the wall, and a wall was in disrepair. (Cambridge Unit Rooms, 226, 228, 230, 231, 233, 210, Cambridge Bistro exit door, and [NAME] Nurse's Station).

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and determine it was clinically appropriate for a resident to self-medicate for 1 of 1 resident randomly observed with medications at the bedside. (Resident 56)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was in reach for 2 of 2 residents reviewed for call lights. (Residents 41 and 116)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide extra portions of oatmeal as preferred and ordered for 1 of 2 residents reviewed for choices. (Resident 51)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely develop dental care plans for 2 of 2 resident's reviewed for dental care (Resident 51 and Resident 12).

Inspectors wroteBased on observation, interview and record review, the facility failed to hold a resident's medication when vital signs were outside parameters for 1 of 2 residents reviewed for Hospitalization, ensure an insulin flex pen was primed with 2 units of insulin prior to the administration of the insulin dosage, and administer lidocaine cream as ordered for 2 of 38 residents observed for quality of care. (Resident 92, Resident 115 and Resident 119)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fluids at the bedside for 1 of 3 residents reviewed for hydration and a diet as ordered for 1 of 1 residents reviewed for nutrition/hydration. (Resident 56 and 116)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely obtain outside dental services and to timely inform the physician of dental pain for 1 of 2 resident's reviewed for dental services ( Resident 51).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control by not utilizing hand hygiene prior to donning gloves to administer eye medications for 2 of 38 residents observations for medication administrations and administered a pill medication that had dropped on the floor for 1 of 1 random observation related to infection control. (Residents 15, 92, and 113)

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 7 residents reviewed for resident rights had their resident's rights honored related to personal property request by a facility staff member. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure a controlled substance medication received from the contracted pharmacy was properly processed and safely stored in the facility for 1 of 3 residents reviewed for pharmacy services. (Resident E)

Inspectors wroteBased on interview and record review, the facility failed to document controlled medications in sufficient detail to ensure an accurate reconciliation of the narcotic count for 4 of 5 residents reviewed for pain and ensure an intravenous (IV) antibiotic was administered timely for a newly admitted resident and completely for 2 of 4 residents reviewed for IV medications (Resident B, Resident L, Resident H, and Resident D).

Inspectors wrote2. The clinical record for Resident M was reviewed on 6/12/25 at 2:20 p.m. The diagnoses included, but were not limited to, anxiety disorder, fracture of the right upper humerus (arm bone). He was admitted to the facility on [DATE]. The acute care hospital discharge instructions, dated [DATE], indicated Resident M was to receive the following medications upon admission to the facility: 1. Aspirin 81 milligram (mg) two times daily, 2. gabapentin (anti-seizure medication) 400 mg three times daily, 3. levetiracetam (anti-seizure medication) 500 mg two times daily, 4. lorazepam (anti-anxiety medication) one mg once daily, 5. methocarbamol (muscle relaxer) 500 mg, two tablets every six hours, 6. oxycodone-acetaminophen (narcotic pain medication) 10 mg - 325 mg, two tablets every four hours as needed for pain, 7. clonazepam (anti-anxiety medication) one mg tablet two times daily, 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely obtain Total Parenteral Nutrition (TPN) for 1 of 4 residents reviewed for medication availability. (Resident H)

Inspectors wroteBased on interview and record review, the facility failed to timely address a resident's pain for 1 of 5 residents reviewed for pain management. (Resident H)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident remained free from significant medication errors by receiving the incorrect narcotic pain medication on multiple occasions for 1 of 4 residents reviewed for medication administration. (Resident L)

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt non- pharmacological interventions for pain, to assess pain levels prior to administering an as needed pain medication, and to assess the effectiveness of as needed pain medication for 1 of 3 residents reviewed for pain (Resident C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control by staff not donning a gown when providing personal care for a resident in enhanced barrier precautions (EBP) and not ensuring soiled linen was not placed directly on the floor for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to address grievances that were reported in resident council meetings for 9 of 9 residents that attended a resident council meeting. (Residents' 1, 8, 12, 28, 39, 63, 67, 71, and 73)

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at palatable temperatures for 4 of 4 residents reviewed for food (Resident 24, Resident 14, Resident C, and Resident 44).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident's ability to communicate and regarding Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for communication and 1 of 1 resident reviewed for PASRR (Resident E and Resident 28).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided and to ensure lotion was applied with personal hygiene for 2 of 6 residents reviewed for activities of daily living (ADLs). (Resident B and Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely provide foot care to 1 of 2 residents reviewed for skin conditions. (Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care planned fall interventions were implemented timely for 1 of 2 residents reviewed for positioning (Resident 63).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control by not donning on personal protective equipment (PPE) while providing respiratory care for 1 of 2 random observations of respiratory care. (Resident 75)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' room in a clean manner and good repair for 2 of 10 residents reviewed for environmental concerns. (Resident 47 and 60)

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring was completed of a resident on anticoagulant medications for 1 of 3 residents reviewed for medications. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to record urine outputs for residents utilizing a urinary catheter for 2 of 3 residents reviewed for urinary catheters. (Resident F and Resident G)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's dignity was maintained for 1 of 3 residents reviewed for abuse. (Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's physician was notified of elevated blood glucose readings per physician's order for 1 of 3 residents reviewed for medication administration. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely reporting of a resident's unusual swelling of his left thigh/leg, which was identified as a left hip fracture, to the State Survey Agency for 1 of 4 residents reviewed for abuse/neglect. (Resident P)

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 reportable incidents reviewed. (Resident N)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered and an Orthopedic appointment and DEXA scan (a bone density test) were scheduled in a timely manner for a resident who had an acute distal tibial and fibula fracture for 1 of 4 residents reviewed for abuse and/or neglect and for 1 of 3 residents reviewed for medications. (Resident F and Resident P)

Inspectors wroteBased on interview and record review, the facility failed to assess or address a resident's pain for 1 of 3 residents reviewed for pain. (Resident N)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate reconciliation of narcotic medications and assure names and signatures of dispensing nurses were present on the narcotic control record for 1 of 3 residents reviewed for medication administration. (Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' clinical records were complete and accurate for 1 of 3 residents reviewed for tube feeding and 1 of 3 residents reviewed for medication administration. (Resident C and Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely obtain medications from the pharmacy, to accurately document administration of medications, and to timely obtain pain medication from the emergency drug supply for 3 of 4 residents reviewed for medication availability. (Resident B, D, and H).

Inspectors wroteBased on observation and interview, the facility failed to maintain the tile walls in a cleanly manner in the kitchen. This had the potential to affect all 117 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physicians' order was in place for the use of total parenteral nutrition (TPN) and clarify physicians; order upon readmission for the utilization of TPN for 1 of 3 residents reviewed for intravenous (IV) therapy. (Resident H)

Inspectors wroteBased on observation and interview, the facility failed to ensure the trash compactor did not have trash items located outside of the unit for 1 of 2 trash disposal items observed.

Inspectors wrote2a The clinical record for Resident D was reviewed on [DATE] at 9:22 a.m. Resident D's diagnoses included, but not limited to, cancer of the tongue, diabetes mellitus Type II, hydrocephalus (extra fluid in the brain causing pressure) with VP shunt (Ventriculoperitoneal shunt, a tube inserted into a hole in the skull too drain excess fluid and relieve pressure on the brain) and status post laryngectomy (removal of larynx, voice box). A university hospital's discharge instructions for Resident D were provided by ED (Executive Director) on [DATE] at 2:24 p.m. The discharge instructions indicated, Resident D had tongue cancer and underwent surgery to remove his larynx (voice box), tongue, the lymph nodes from both sides of his neck and a VP shunt revision. The medication reconciliation indicated Resident D was on the following medications: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses were able to demonstrate competency in skills and techniques necessary to input physicians orders into the electronic medical record, recognize a change in condition, and follow-up with a change in condition. This had the potential to affect all 108 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff to carry out timely meal service at the facility for 96 of 108 residents who are served food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 96 of 108 residents who eat food from the kitchen. (Residents 8, 24, 225, 226, and 228)

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store clean dishes, bread in the dry storage area, and refrigerated foods and maintain kitchen equipment in a clean, sanitary condition for 96 of 108 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the floors in a cleanly manner in the kitchen for 96 of 108 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective training program for all new and exisiting staff by determining the amount and types of training necessary based on the facility assessment that included, but were not limited to, inputting physician orders, clarifying physician orders, identification of a change in a residents' condition, follow-up with a change in condition, notification of the physician, and documentation in the medical record. The facility failed to ensure newly hired staff received orientation that was based on the training topics that aligned with the facility assessment. This had the potential to affect all 108 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment for 7 of 12 resident rooms observed. (Residents 7, 32, 43, 62, 228, 226, and 69)

Inspectors wroteBased on observation and interview, the facility failed to protect and value a resident's private space by not knocking on doors and requesting permission before entering a resident's room for 2 residents during a random observation (Resident 52 and 38) and not taking into account the physical limitations of a resident by not clearly explaining to a resident who is blind what she had placed on his bedside tray table nor where it was placed so that he may find it for 1 of 1 residents observed during a random observation (Resident 52).

Inspectors wroteBased on observation, interview and review, record the facility failed to have the Interdisciplinary team (IDT) determine and document a self medication assessment was clinically appropriate for 2 of 2 residents randomly observed with medications at the bedside. (Resident 12 and 83)

Inspectors wroteBased on observation,interview, and record review, the facility failed to ensure continued provision of a wheel chair and to ensure a resident's television was positioned for viewing for 1 of 4 residents reviewed for personal property and 1 of 2 residents reviewed for accommodation of needs. (Resident E and Resident 50) .

Inspectors wroteBased on interview and record review, the facility failed to timely address a resident's guardian's grievances and to promptly resolve an oral grievance from a resident regarding missing clothing items for 2 of 4 residents reviewed for personal property. (Resident E and Resident 32)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of a resident's MDS (Minimum Data Set) assessment for 1 of 1 resident reviewed for PASRR (Pre admission Screening Resident Review) and 2 of 3 residents reviewed for MDS accuracy. (Resident 26, 83, and 69)

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely update an ADL (Activities of Daily Living) care plan to reflect the resident's refusal of care and to ensure a resident's dialysis care plan was updated for 1 of 4 residents reviewed for ADL care and 1 of 2 residents reviewed for Dialysis. (Resident 69 and Resident C)

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers that included shaving and by not ensuring twice weekly showers/complete bed baths were provided for 2 of 4 residents reviewed for Activities of Daily Living. (Resident 225 and Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent a resident's range of motion from declining and failed to ensure a resident with limited range of motion received appropriate treatment, equipment, and services to prevent further decrease in range of motion for 2 of 3 residents reviewed for range of motion ( Resident 34 and 61).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for the administration of gastrostomy tube (g-tube) bolus feedings for a random observation during medication administration. (Resident 95)

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure a resident had an inner canula present in her tracheostomy, as ordered by a physician, for 1 of 1 resident reviewed for tracheostomy care (Resident 61).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receiving dialysis services had physician orders for dialysis services and monitoring of the site for 1 of 2 residents reviewed for dialysis. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to accurately monitor, document, and track behaviors for 1 of 5 residents reviewed for unnecessary medications, 1 of 4 residents reviewed for dignity, and 1 of 1 resident reviewed for abuse.(Resident 34, Resident F, and Resident 8).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident was provided clothing for 1 of 4 residents reviewed for Activities of Daily Living. (Resident 225)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts did not contain expired medications along with loose pills located in 2 out of 4 medication carts observed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided milk as preferenced and failed to ensure a resident's preference for an alternative food item, which was on the always available menu, was always available for 2 of 6 residents reviewed for food. (Resident 225 and Resident 52)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed prior to staff touching pills with their bare hands and ensure personal protective equipment (PPE) was donned prior and during administration of a aerosol generating procedure (AGP) for 2 of 14 residents observed for medication administration. (Resident 100 and Resident 85)

Inspectors wroteBased on interview and record review, the facility failed to prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of all pre and post discharge medications, and a discharge plan of care for 3 of 3 residents reviewed for discharge. (Resident B, Resident F and Resident G)