Divine Rehabilitation and Nursing at Canal Pointe

Inspectors wroteBased on observation, interview, and policy review the facility failed to provide food at appetizing temperatures. This had the potential to affect 108 residents receiving meals from the kitchen. The facility identified three residents (#31, #51, and #108) who received nothing by mouth (NPO). The facility census was 111.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 108 residents receiving meals from the kitchen. The facility identified three residents (#31, #51, and #108) as receiving nothing by mouth (NPO). The facility census was 111.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were securely stored. This affected one resident (Resident #212) and had the potential to affect all residents residing at the facility. The facility also failed to discard expired medications. This had the potential to affect all of the residents residing in the facility. The facility census was 111 residents.

Inspectors wroteBased on observation, interview, review of the facility policy and record review the facility failed to ensure foods in unit refrigerators were labeled, dated and not retained when expired and stored in a clean environment. This had the potential to affect 108 residents receiving meals from the kitchen as three residents (#63, #104 and #106) were ordered nothing-by-mouth (NPO). Facility census was 111.

Inspectors wroteBased on review of personnel files and interviews with staff, the facility failed to ensure employees received the required annual training. This affected 13 of 13 employees reviewed for personnel files and had the potential to affect all 111 residents residing in the facility.

Inspectors wroteBased on review of personnel files and interviews with staff the facility failed to provide regular training for the certified nursing assistants (CNAs) for their 12 in-services annually. This had the potential to affect all 111 residents residing in the facility.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure residents had a safe, clean, homelike environment. This affected two (Residents #3 and #6) reviewed for their bedroom environment and had the potential to affect an additional 78 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #17, #18, #20, #21, #22, #23, #24, #26, #27, #28, #29, #30, #32, #33, #34, #37, #38, #39, #40, #41, #42, #44, #45, #47, #49, #50, #52, #53, #56, #58, #59, #60, #61, #62, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #77, #78, #82, #85, #86, #87, #88, #89, #90, #91, #92, #93, #96, #97, #103, #104, #112, #211, #212, #213, and #311) residing on the second and third floor of the facility. The facility census was 111.

Inspectors wroteBased on interview, record review, self-reported incident (SRI) review and policy review, the facility failed to thoroughly investigate allegations of abuse. This affected four (Residents #48, #50, #58, #214) of four residents reviewed for abuse. The facility census was 111.

Inspectors wroteBased on record review, observation, interview and review of facility policies, the facility failed to ensure comprehensive care plans were in place relative to residents' medical, psychosocial and mental needs. This affected five (Residents #6, #46, #69, #102 and #107) out of 37 resident records reviewed. The facility census was 111.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to timely assess and/or accurately assess residents for smoking. This affected four (Residents #22, #58, #64 and #86) of four residents reviewed for smoking. The census was 111.

Inspectors wrote4. Review of the medical record for Resident #48 revealed an admission date of 01/25/23 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, and diabetes mellitus. Review of the MDS assessment for Resident #48 dated 04/01/25, revealed the resident was cognitively intact. Review of the MAR for Resident #48 dated May 2025 revealed medications were administered several hours after the medication was ordered: metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid scheduled for 05/04/25 at 9:00 A.M. were given at 11:27 A.M., Macrobid, Colchicine, Eliquis, trazodone scheduled for 05/04/25 at 9:00 P.M. were given at 11:27 P.M., insulin Lispro scheduled for 05/04/25 at 8:00 A.M. was given at 10:46 A.M., Depakote, metoprolol, Entresto, Tamsulosin scheduled for 05/04/25 at 9:00 P.M. [...]

Inspectors wroteBased on observation, interview, menu review and review of the menu spreadsheet, the facility failed to provide food items at the designated portions as written. This affected 101 residents receiving food from the kitchen as three residents (#63, #104 and #106) were ordered nothing-by-mouth (NPO) and seven residents (#9, #10, #24, #54, #74, #95 and #112) were observed to receive alternate meals during the observation. The facility census was 111.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure the physician and resident's responsible party were notified when lab draws were not completed according to the physician/certified nurse practitioner (CNP) orders. This affected one (Resident #66) of three residents reviewed for notification. The facility census was 111.

Inspectors wroteBased on medical record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to prevent resident-to-resident between Residents #48 and #214. This affected two (Residents #48 and #214) of four residents reviewed for abuse. The facility census was 111. Findings Include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, heart disease, major depressive disorder, post-traumatic stress disorder (PTSD), a left below the knee amputation, and an internal cardiac defibrillator. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact, refused aspects of care daily, and needed no assistance with personal care. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the State agency for one (Resident #58) of four residents reviewed for abuse. The facility census was 111.

Inspectors wroteBased on interview and record review, the facility failed to monitor Resident #66's daily fluid intake and daily urine output related to a diagnosis of urinary retention requiring the use of an indwelling urinary catheter and discontinuation of the indwelling urinary catheter. This affected one (Resident #66) of two residents reviewed for indwelling catheters. The facility census was 111.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #67 received all nutritional interventions recommended by the registered dietitian to treat and prevent significant weight loss. This affected one resident (Resident #67) of three residents reviewed for nutrition. The facility census was 111.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure orders were in place for the administration of oxygen and failed to date oxygen tubing as required. This affected one resident (#107) of one resident reviewed for oxygen and had the potential to affect an additional 13 residents (#1, #57, #65, #69, #74, #80, #84, #89, #97, #99, #106, #262 and #311) the facility identified as receiving oxygen in the facility. Facility census was 111.

Inspectors wroteBased on interview and record review the facility failed to obtain communication from the dialysis provider after each dialysis treatment. This affected one resident (Resident #94) of one resident reviewed for dialysis. The facility census was 111. Findings Include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis of the left ankle and foot, diabetes with diabetic neuropathy, end stage renal disease dependent on dialysis, congestive heart failure, high blood pressure, Tourette's disorder, schizophrenia, and anxiety. Review of the physician's orders revealed Resident #94 attended dialysis on Mondays, Wednesdays, and Fridays. The resident was on a fluid restriction of 2000 milliliters (ml) per 12 hour shift. [...]

Inspectors wroteBased on record review, observation, interview, and review of the facility policy, the facility failed to ensure a safe environment for Resident #212. This affected one (Resident #212) of one resident reviewed for suicidal ideations. The facility census was 111.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure blood sugar results were obtained prior to eating the breakfast meal for Resident #72 and failed to prime the insulin pen prior to administering the insulin injection for residents #72 and #19. This affected two (Residents #19 and #72) observed for blood sugar assessments and insulin administration and had the potential to affect an additional 24 (Resident #2, #5, #16, #17, #21, #23, #24, #25, #29, #34, #44, #48, #51, #53, #55, #62, #67, #68, #69, #83, #211, #212, #262, and #311) identified by the facility as requiring a blood sugar assessment prior to meals and or requiring insulin via insulin pen. The facility census was 111.

Inspectors wroteBased on record review, interview, pharmacy medical record review and lab requisition review, revealed the facility failed to ensure the physician ordered labs were completed timely for Resident #66. This affected one (Resident #66) of five residents reviewed for unnecessary medications. The facility census was 111.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control practices and or ensure personal protective equipment (PPE) was readily available for two residents, Resident #6 and #104 who required enhanced barrier precautions (EBP). This affected two residents (#6 and #104) of two residents reviewed for EBP and had the potential to affect all residents residing at the facility. The facility census was 111.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure all medications were disposed of in a safe and secure manner. This had the potential to affect an unidentified number of staff and 46 residents (#1, #4, #9, #10, #17, #18, #19, #20, #22, #23, #25, #27, #28, #30, #32, #35, #38, #39, #40, #49, #50, #51, #52, #55, #56, #59, #60, #65, #66, #67, #70, #73, #74, #75, #76, #77, #80, #81, #82, #84, #89, #90, #94, #97, #99, and #100) residing on the third floor of the facility who potentially could have accessed the unsecured medications. The facility census was 101.

Inspectors wroteBased on review of the facility Self-Reported Incident (SRI), record reviews and interviews the facility failed to ensure Resident #98 was free from misappropriation. This affected one resident (Resident #98) of three residents reviewed. The census was 103.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS) for the third fiscal quarter of 2023. This had the potential to affect all 105 residents in the facility.

Inspectors wroteBased on observations, review of the medical record, interview with staff and review of the facility policy, the facility failed to ensure a comfortable water temperature in Resident #75's room and failed to ensure a comfortable temperature in the dining room on floor one. This affected one resident (Resident #75) but had the potential to affect all the resident on the 300 hall unit and affected three residents ( Resident #67, #69 and #74) in the first-floor dining room. The facility census was 105.

Inspectors wroteBased on observation and interview the facility failed to store flour in a manner to prevent contamination. This had the potential to affect all 105 residents in the facility. The facility census was 105. All residents receive meals from the kitchen. Findings Included: On 11/27/23 at 9:00 A.M. a tour of the kitchen with the Director of Dining Services (DDS) #69 revealed two styrofoam cups in the flour bin. This was verified by DDS #69 at the time of the kitchen tour. A review of the policy titled, Food Safety Requirements that was undated revealed the definition of contamination is the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. It also revealed that food safety practices shall be followed throughout the facility's entire food handling process. [...]

Inspectors wrote2. Review the personnel records for State Tested Nurses Aide (STNA) #70 revealed a hire date of 08/05/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Review the personnel records for STNA #75 revealed a hire date of 06/09/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Interview on 11/30/23 at 11:15 A.M. with the Director of Nursing (DON) confirmed the TB tests were not administered timely. Review of the facility policy titled Tuberculosis Risk Assessment Worksheet dated 03/02/23, revealed screening of employees for TB infection on would occur annually. [...]

Inspectors wroteBased on record review, interview, and facilities policy review, the facility failed to follow their policy for abuse in regard to allegations of resident to resident abuse. This affected three residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105.

Inspectors wroteBased on record review, interview, and facilities policy review, the facility failed to thoroughly investigate a witnessed incident of Resident to Resident abuse. This affected three Residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (Resident #9) regarding dental status. This affected one resident (Resident #9) of nine reviewed for assessments. The facility census was 105.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure anti-embolic stockings (stockings used to prevent swelling or blood clots) were applied as ordered. This affected one resident (Resident #77) of three reviewed. The facility census was 105.

Inspectors wroteBased on observations, review of the medical record, and interviews with staff the facility failed to ensure fall intervention were in place for Resident #26. This affected one resident (Resident #26) of six reviewed for accidents. The facility census was 105.

Inspectors wroteBased on interview, record review, and facilities policy review, the facility failed to ensure pre and post dialysis assessments and vitals and weights were obtained as ordered for one resident (Resident #98). This affected one resident (Resident #98) of one review for dialysis services. The facility census was 105.

Inspectors wroteBased on review of the medical record, review of the pharmacy recommendation, interview with staff, and review of facilities policy, the facility failed to ensure pharmacy recommendation were addressed and implemented timely. This affected one resident ( Resident #26) of five reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on observation, interview, record review, and facilities policy review, the facility failed to ensure nonpharmacological interventions were in place prior to administering as needed (prn) pain medication and failed to ensure parameters were in place to determine which type of pain medication to administer. This affected one resident (Resident #53) of six reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on record review, interview, and facilities policy review, the facility failed to ensure one resident (Resident #97) had a diagnosis for a prescribed antipsychotic. This affected one resident (Resident #97) of six reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on observation, record review, interview, and facilities policy review, the facility failed to ensure Resident #63's, Resident #74's and Resident #95's medications were administered as ordered by the physician causing a medication error rate of 45 percent. This affected three ( Resident #63,#74, and #95) out of five residents observed during medications administration. The facility census was 105.

Inspectors wroteBased on record review and interview the facility failed to ensure annual performance evaluations and twelve hours of regular in-service education were completed as required for State Tested Nursing Assistants (STNAs). This affected four of four STNA personnel files reviewed and had the potential to affect all 95 residents currently residing in the facility.

Inspectors wroteBased on review of the Nursing Home Resident's [NAME] of Rights, medical record review, and interview the facility failed to respect a resident's right to determine when to go to bed. This affected one (Resident #145) of two residents reviewed for choices (18 residents were interviewed regarding choices).

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure an allegation of abuse was reported. This affected one (Resident #145) of three residents reviewed for abuse.

Inspectors wroteBased on medical record review, observations, and interview the facility failed to ensure one (Resident #145) of four residents reviewed for activities of daily living received bathing assistance. The facility identified 81 residents who required assistance with or who were dependent on staff for bathing.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to ensure an activity program was implemented in accordance with a resident's assessment and preferences. This affected one (Resident #59) of two residents reviewed for activities.

Inspectors wroteBased on resident interview, medical record review and staff interview the facility failed to ensure physician's orders for foot care were implemented and provided as ordered. This affected one (Resident #36) of one resident reviewed for foot care services. The facility census was 95.

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to provide restorative range of motion services as indicated. This affected two (Residents #69 and #76) of three residents reviewed for range of motion. The facility census was 95.

Inspectors wroteBased on observation, medical record review, staff interview and policy review the facility failed to ensure fall interventions were in place as ordered for one (Resident #62) of four residents reviewed for falls. The facility also failed to ensure monitoring devices were in place as ordered to prevent unwanted exit from the facility for one (Resident #43) of two residents reviewed for supervision. The facility census was 95.

Inspectors wroteBased on observation, medical record review and interview the facility failed to ensure implementation of physician orders for residents with tracheostomies. This affected two (Residents #20 and #59) of three residents reviewed for respiratory care. The facility identified two residents with tracheostomies.

Inspectors wroteBased on medical record review, observation, policy review, and interview the facility failed to maintain infection control practices during tracheostomy care. This affected one (Resident #59) of one resident observed for tracheostomy care.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure antibiotic assessments were used to ensure appropriate antibiotic use. This affected one (Resident #62) of five residents reviewed for medications. The facility census was 95.