Center Point Health Care and Rehab

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents who required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain oral hygiene for 1 (#1) of 3 residents reviewed for ADLs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to have sufficient LPN staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment and observations of untimely medication administration. The deficiency had the potential to affect the facility's total census of 155 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 36% during the medication administration observation. A total of 36 opportunities were observed, which included 13 medication errors for Resident #151 out of 5 residents observed for medication administration. This failed practice had the potential to affect any of the 155 residents currently residing in the facility. Review of the facilities policy titled, Medication Administration with a revised date of 04/2022, revealed, in part:11. Compare medication with MAR to verify resident name, medication name, form, dose, route and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure medications were properly stored in 1 (MedCart 1) of 4 medication carts observed for medication storage. Review of the facility's policy titled Medication Storage dated 01/2026 revealed in part, the following:1.a. All drugs will be stored in locked compartments (medication carts). An observation was made on 04/21/2026 at 2:32 p.m. of MedCart 1 unlocked, unsupervised, and located outside the nurses' station. Multiple residents were observed walking near the unlocked, unsupervised medication cart. An interview was conducted on 04/21/2026 at 2:40 p.m. with S2ADON. She confirmed MedCart 1 was unlocked and supervised. She opened the top drawer of MedCart 1 and observed 3 medication cups, each with loose pills located inside. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to perform proper hand hygiene and gloving practices for 2 (#1 and #106) of 8 residents observed during direct care. Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to perform proper hand hygiene and gloving practices for 2 (#1 and #106) of 8 residents observed during direct care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident's room was clean and maintained in a sanitary manner for 1 (#101) of 2 sampled residents reviewed for environment. The facility failed to ensure Resident #101's room and restroom were properly cleaned and free of odor. Review of the facility's policy titled Routine Cleaning and Disinfection, with an effective date of 10/2025, revealed the following, in part:Policy:It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines:3. Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas12. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure prescribed medications were available for administration for 1 (#151) of 5 residents reviewed for medication availability. This failed practice had the potential to affect any of the 152 residents currently residing in the facility. Review of facility's policy titled Medication Reordering revealed the following, in part:2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.3. When administering medications, nurses must monitor remaining supply and reorder medications timely to prevent omissions, time permitting. Review of Resident #151's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnosis including Essential Hypertension. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide appropriate treatment and services for 1 (#1) resident of 4 residents reviewed for tube feedings. The facility failed to ensure:1. Resident #1's tube feeding bag was changed every 24 hours; and 2. Resident #1's tube feeding formula and free water flushes were administered per physician's orders. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Cerebral Infarction, Dysphagia following Cerebral Infarction, and Gastrostomy status. Review of Resident #1's Current Physician Orders revealed an order dated 10/23/2025 for enteral feed every shift: Continuous feed: Jevity 1.5 at 70 ml per hour and 170 ml water flush every four hours. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 60% during the medication administration observation. A total of 65 opportunities were observed, which included 39 medication errors with Resident #3, #R1, #R2, #R3, and #R4 of 5 residents observed for medication administration. This failed practice had the potential to affect any of the 152 residents currently residing in the facility. Review of the facilities policy titled, Medication Administration with a revised date of 04/2022, revealed, in part: 11. Compare medication with MAR to verify resident name, medication name, form, dose, route and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Resident #3 Review of Resident #3's current Physician Orders revealed: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure prescribed medications were available for administration for 1 (#3) of 3 residents reviewed for medication availability. This failed practice had the potential to affect any of the 152 residents currently residing in the facility. Review of facility's policy titled Medication Reordering revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. When administering medications, nurses must monitor remaining supply and reorder medications timely to prevent omissions, time permitting. Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnosis including Essential Hypertension. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality for 1 (#1) of 3 residents reviewed with feeding tubes. The facility failed to ensure nursing staff:Clarified Resident #1's tube feeding orders with the physician; andVerified accurate administration of Resident #1's tube feeding rate prior to documenting administration of tube feedings.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to ensure the resident received tube feedings based on the comprehensive assessment for 1 (#1) of 3 residents reviewed with feeding tubes.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions for 1 (#1) of 2 (#1 and #3) residents reviewed for discharge. The facility failed to ensure: 1. The discharge needs of the resident were identified and resulted in the development of a discharge plan;2. Involve the interdisciplinary team in the ongoing process of developing the discharge plan;3. Document the resident had been asked about their interest in receiving information regarding returning to the community; and 4. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the resident or RP (Responsible Party) with written notice, which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents. Review of the facility's Bed Hold and Returns policy, revised on 04/2025, revealed, in part:Policy:It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines:1. The facility will issue (2) written notice of bed hold policy to the resident/or resident representative as follows:1. As part of the admission packet and2. At the time of a transfer to the hospital or a therapeutic leave. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S18DW was competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service when meals were served late on 05/05/2025 and 05/06/2025. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 2 (#19 and # 92) of 6 (#9, #19, #36, #53, #92 and #138) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#11 and #111) of 4 (#9, #11, #30, and #111) residents reviewed for ADL's. The facility failed to: 1. trim fingernails for Resident #111; and 2. provide incontinent care in a timely manner for Resident #11.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received therapeutic diets as ordered by the physician for 3 of 3 (#7, #39, and #40) residents reviewed with double/large portions with meals.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure meals were provided at regular meal times comparable to normal mealtimes in the community and consistent with facility scheduled meal times for 2 (Hall A and Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. The kitchen floor remained clean; 2. Food was properly sealed in the refrigerator of the facility's kitchen; 3. Food cans and containers remained uncompromised in the dry storage areas of the facility's kitchen; 4. The dishes were cleaned and sanitized in a way that minimized the spread of foodborne illness; and 5. The food service area remained in a sanitary condition during the meal serving process. This deficient practice had the potential to affect the 140 residents who were served food from the kitchen.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure patient care equipment was maintained in safe operating condition for 2 (#92 and #97) of 2 (#92 and #97) sampled residents reviewed for call light safety.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with a mental disorder had an accurate Pre-admission Screening for 1 (#138) of 6 (#9, #19, #36, #53, #92, and #138) residents reviewed for PASSAR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 1 (#30) of 30 residents reviewed for comprehensive care plans in the final sample.

Inspectors wroteBased on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1(#19) of 31 residents observed in the final sample.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#111) of 5 (#104, #111, #208, #337, #342) residents reviewed for enteral feedings. The facility failed to ensure: 1. The enteral feeding flush bag was appropriately labeled with a date and time; and 2. The enteral feeding pole was kept clean and free of dried formula.

Inspectors wroteBased on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#138) resident reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor and flush according to professional standards.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1(#9) of 31 residents investigated in the final sample.

Inspectors wroteBased on observation and interviews, the facility failed to dispose of garbage properly by failing to ensure: 1. Trash was contained in the facility's kitchen and outdoor dumpster; and 2. Garbage receptacles and dumpsters were covered.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#84) of 7 (#9, #11, #49, #56, #84,#109, and #293) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing gastrostomy feeding to a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the results of the most recent standard survey and complaint survey were posted in a place readily accessible to residents, family members, and legal representatives. This deficient practice had the potential to affect the 148 residents who currently resided in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Develop a facility assessment which addressed staff training for skills and non-pharmacological interventions and the process to evaluate competency of skill sets necessary to provide the level and type of care necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia Disorder, Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD); and 2. Provide staff training for non-pharmacological interventions and ensure competency in the skill sets necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia, PTSD and SUD for 4 of 4 (S4LPN, S5LPN, S6RN, and S7MSW) Personnel Files reviewed. This deficient practice had the potential to affect a current census of 147 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to ensure: 1. Resident #2 was coded for diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD); and 2. Resident #2 was coded for his most recent Gradual Dose Reduction (GDR) date and the provider's response. This deficient practice had the potential to affect a current census of 147 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to develop a care plan for Resident #1's diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD). This deficient practice had the potential to affect a current census of 147 residents.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for therapeutic diets. The facility failed to ensure Resident #2's diet order was updated in the electronic medical record. The deficient practice had the potential to affect the 134 residents residing in the facility receiving physician ordered nutrition.

Inspectors wroteBased on observations, interviews and record review, the facility failed to post nurse staffing data on a daily basis which included the total resident census number, and total number and actual hours worked for licensed and unlicensed nursing staff. This deficient practice had the potential to affect any of the 142 residents currently residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASARR) Level II by failing to: 1. Refer all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review after expiration of 6 month temporary effective period for 1 (#5) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASARR; and 2. Incorporate a PASARR Level II determination and recommendations into a resident's care plan for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to implement interventions after weight loss for 1 (#45) of 5 (#17, #19, #45, #52, and #132) residents reviewed for nutrition.

Inspectors wroteBased on interviews and record review, the facility failed to ensure: 1. Physician ordered narcotic pain medication was available for administration for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management; and 2. As needed narcotic pain medication was documented as administered on the MAR for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community for 1 (Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. This had the potential to effect 141 residents who were served from the kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 142 residents who currently reside in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate a resident's needs for tube feeding management for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Discharge MDS assessment was completed and transmitted timely for 1 (#105) of 2 (#100 and #105) residents reviewed for Resident Assessment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure: 1. A record of the Level 1 Pre-admission Screening and Resident Review (PASRR) form was maintained in the resident's record for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR; and 2. A resident with a mental disorder had an accurate Pre-admission Screening for 1 (#46) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure documentation of weekly nurses' notes were filed as documented on the TAR for 1 (#46) of 32 residents investigated in the final sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications by failing to ensure there was an acceptable diagnosis for antidepressant and anti-anxiety medications for 1 (#72) of 5 (#10, #46, #72, #117 and #132) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#28) of 34 residents observed during initial screening of residents upon facility entrance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 (#132) of 3 (#102, #131, #132) residents reviewed for food.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#30) of 36 residents reviewed in the initial screening for advanced directives.

Inspectors wroteBased on record reviews and interviews, the facility failed to coordinate hospice care services to ensure a system was in place to update hospice binder with current orders, certification period and care plans for 1 (#30) of 4 (#28, #72, #30 and #78) residents reviewed for hospice care.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S13TN and S16CNA wore proper Personal Protective Equipment while providing care for 1 (#72) of 3 (#1, #19, and #72) sampled residents reviewed for peg tube care.