Centerburg Pointe

Inspectors wroteBased on record review, interviews and observations, the facility failed to ensure proper hand hygiene for two Residents #245 and Resident #290. This affected two Residents (#245 and #290) of the six residents reviewed. The facility census was 71.

Inspectors wroteBased on medical record review, staff interview, review of facility investigation report, review of personnel file, and review of facility policy, the facility failed to protect Resident #55 from assault by Certified Nursing Assistant (CNA) #599. This affected one resident (#55) of four residents reviewed for facility self-reported incidents and had the potential to affect all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, review of the medical record, review of the facility's investigation, resident interview, staff interview and review of the facility policy, the facility failed to protect Resident #68 from misappropriation of his Oxycodone (opioid) medication. This affected one Resident (#68) of three reviewed for medication administration. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, review of facility investigation report, review of personnel file, and review of facility policy, the facility failed to report to law enforcement an incident of staff to resident abuse. This affected one resident (#55) of four residents reviewed for facility self-reported incidents and had the potential to affect all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteBased on observation, staff interview, medical record review and policy review, this facility failed to ensure a 5% or less medication error rate was maintained when five medication errors out of 26 opportunities were observed resulting in a medication error rate of 19%. This affected one (Resident # 86) of the three residents observed for medication administration. The facility census was 68.

Inspectors wroteBased on record review, observation, interview, policy review and review of the Center of Disease Control recommendations, the facility failed to ensure appropriate infection control procedures were followed while incontinence care was provided. This affected one (Resident #2) of one residents observed for incontinence care. Facility census was 68.

Inspectors wroteBased on interview, record review, and review of facility policy the facility failed to notify the physician of a change in Resident #71's skin condition. This affected one resident (#71) of two residents reviewed for pressure ulcers. The facility census was 70.

Inspectors wroteBased on interviews and medical record reviews the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected three (#69, #174 and #175) of four reviewed for discharge. The total facility census was 70. Findings Include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, her diagnoses included cirrhosis of liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24 with diagnoses including cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #53. This affected one resident of six closed records reviewed. The facility census was 70.

Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to obtain a discharge physician order when residents were being discharged from the facility. This affected three (#69, #174, and #175) of four residents reviewed for discharge. The census was 70.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #4's nails were maintained in a clean manner and at a good length. This affected one resident (#4) of three residents reviewed for activities of daily living (ADL). The facility census was 70.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure physician orders were present for therapy services prior to delivering services to one (#42) of one reviewed for hospice services, and the facility failed to follow practitioner recommendation for vascular surgery consult for one (#35) of one reviewed for non pressure skin condition. The census was 70. Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date of 06/29/21, diagnoses included Alzheimer's Disease, dementia, anxiety, bi-polar disorder and a history of falling. Resident #42 admitted to hospice services on 10/31/23 and was a Do Not Resuscitate Comfort Care (DNR-CC). Observation on 03/18/25 at 11:30 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor Resident #4 and Resident #20's use of a splint. This affected two residents (#4 and #20) of two residents reviewed for limited range of motion. The facility census was 70.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place and falls were documented for one (#11) of two residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on interview, medical record review, and facility policy review the facility failed to ensure an indwelling foley catheter was inserted correctly and monitored after insertion. This had the potential to affect one (#24) of two reviewed for catheter care. The census was 70.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to maintain availability of ordered pain management medications for one resident (Resident #33) out of two residents reviewed for pain management. The facility census was 70.

Inspectors wroteBased on interview and record review the facility failed to ensure pre and post dialysis assessments were completed for Resident #20. This affected one resident (#20) of one resident reviewed for dialysis. The facility census was 70.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #20's medication was held as ordered by the physician This affected one resident (#20) of five residents reviewed for unnecessary medications. The facility census was 70.

Inspectors wroteBased on interview and record review the facility failed to follow medication parameters for one (#20) of five reviewed for unnecessary medication. The facility census was 70.

Inspectors wroteBased on interview and record review the facility failed to ensure fluid restrictions were followed as ordered for two residents (#20 and #34) out of three residents reviewed for conditions that required fluid restrictions. The facility census was 70.

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review a facility investigation, review of hospital documentation and facility policy review the facility failed to use a mechanical lift sling pad correctly resulting in a fall from a mechanical lift. This affected one resident (Resident #73) of two residents reviewed for accidents. The facility census was 71. Findings Include: A review of Resident #73's medical record revealed admission date 10/02/24 with diagnoses including but not limited to respiratory failure with ventilator dependency, tracheostomy, dysphagia, chronic obstructive pulmonary disease (COPD), and high blood pressure. A review of Resident #73's admission fall risk assessment revealed Resident #73 was at risk for falls related to impaired mobility. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview the facility failed to have eight consecutive hours daily of Registered Nurse (RN) coverage in the facility. This had the potential to affect the 59 residents who resided at the facility.

Inspectors wroteBased on record review, review of the staffing tool and resident and staff interviews, the facility administration failed to ensure there was sufficient direct care staff at all times in the facility to meet the minimum staffing requirement of two point five (2.5) hours of direct care per resident per day. This had the potential to affect all 59 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for influenza and pneumococcal immunizations. This affected four residents (#17, #6, #106, and #16) of five residents reviewed for immunizations. The facility census was 59.

Inspectors wroteBased on record review and resident and staff interviews, the facility did not ensure Resident #105 participated in and received a copy of her baseline care plan within 48 hours of admission. This affected one resident (Resident #105) of two residents reviewed for baseline care plans. The facility census was 59. Findings Include: Review of Resident #105's medical record revealed the resident admitted on [DATE] with diagnoses including diabetes, atrial fibrillation, hypertension and displaced intertrochanteric fracture of left femur. The resident discharged on 10/11/23. Resident #105 was listed as her own guarantor, and no other responsible parties were listed. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure physician orders were obtained to provide treatment to an area of skin impairment for Resident #40. The affected one (#40) resident of seven residents reviewed for wounds. The facility census was 59. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis and chronic venous hypertension with ulcer and inflammation to lower left leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no hallucinations, required supervision for activities of daily living, was occasionally incontinent of bladder and always continent of bowel. The resident was coded as being at risk for pressure ulcers but as not having any pressure ulcers. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure pressure reducing interventions were in place for Resident #9, #10, and #305. This affected three residents (#9, #10, and #305) of seven residents reviewed for skin impairment or pressure ulcers. The facility census was 59.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place for Resident #1 and #38 and failed to ensure Resident #29 had smoking assessment upon admission and quarterly This affected three residents (#1, #38, and #29) of six residents reviewed for accidents/hazards. The facility census was 59.

Inspectors wroteBased on record review, review of facility policy and interviews, the facility failed to ensure weights were completed as ordered and the physician was notified of weight changes for Resident #22 and Resident #305. This affected two residents (#22 and #305) out of five residents reviewed for nutrition. The facility census was 59.

Inspectors wroteBased on record review and interviews, the facility failed to ensure pain was addressed timely and appropriately for Resident #258. This affected one (Resident #258) of four residents reviewed for pain. Facility census was 59.

Inspectors wroteBased on record review, observation, interview and review of facility policy, the facility did not ensure an assessment for the appropriateness of use of bed rails versus alternatives was completed for Resident #259. This affected one resident (#259) of four residents reviewed for accidents/hazards. The facility census was 59.

Inspectors wroteBased on interview and record review the facility failed to monitor blood pressure according to medication parameters and failed to ensure parameters were in place for pain medication for Resident #35. This affected one resident (#35) of six residents reviewed for medications. The facility census was 59.

Inspectors wroteBased on record review and interviews, the facility did not ensure Resident #258 was administered medications in accordance with physician orders and therefore free of significant medication errors. This affected one resident (#258) of six residents reviewed for medication administration. The facility census was 59.

Inspectors wroteBased on record review, observation and interview, the facility did not keep an accurate record of skin impairment and wound status in the medical record for Resident #10. This affected one (Resident #10) of seven residents reviewed for skin impairments. The facility census was 59.

Inspectors wroteBased on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for COVID-19 immunization. This affected three residents (#17, #6, and #16) of five residents reviewed for immunizations. The facility census was 59.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain comfortable sound levels throughout the facility when Resident #17 frequently played his music too loud and Resident #293 could frequently be heard yelling out. This affected eight residents (#293, #17, #2, #26, #28, #30, #37 and #342) and had the potential to affect 11 additional residents (#41, #294, #194, #33, #3, #242, #343, #35, #34, #7 and #15) who resided on the B and D units of the facility. The facility census was 41.

Inspectors wroteBased on record review, staff interview and facility policy and procedure review the facility failed to develop a care plan for Resident #37 related to the use of adaptive equipment. This affected one resident (Resident #37) of 14 residents reviewed for care plans.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure adaptive equipment, including an elbow splint, blue bilateral spacer wedges and pillow between the resident's knees were provided to maintain the resident's functional mobility and failed to ensure staff only documented the delivery of care when it was actually provided. This affected one resident (#37) of three residents reviewed for adaptive equipment.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #28 was instructed to rinse his mouth with water following the administration of Flovent inhalation medication to decrease the resident's risk of developing oropharyngeal candidiasis. This affected one resident (#28) of ten residents observed for medication administration.

Inspectors wroteBased on observation, record review and interview the facility failed to adequately monitor areas of skin impairment/breakdown for Resident #30 and failed to ensure Resident #20 had physician ordered heel suspension boots in place for prevention of skin break down. This affected two residents (#20 and #30) of four residents reviewed for skin conditions.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to check for proper gastrostomy tube placement for Resident #293 prior to administering medications to prevent complications. This affected one resident (#293) of ten residents observed for medication administration.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to implement an effective and individualized pain management program for Resident #243, including the administration of pain medication as ordered by the physician. This affected one resident (#243) of 10 residents reviewed for procuring ordered medications.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to monitor behaviors and/or for side effects of medication for Resident #30 and Resident #40, who were prescribed psychotropic medication. The affected two residents (#30 and #40) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure Resident #20's room was maintained in a clean and sanitary manner. This affected one resident (#20) of 41 residents whose rooms were observed.

Inspectors wroteBased on record review and interview the facility failed to ensure resident mail was readily available to residents and delivered on Saturdays. This affected three residents (#18, #26, and #41) and had the potential to affect all 41 residents residing in the facility.