Eagle Pointe Skilled Nursing & Rehab

Inspectors wroteBased on record review, resident and staff interviews and facility policy review, the facility failed to make prompt efforts and resolve a resident grievance involving staff smelling of marijuana while providing care. This affected one resident (Resident #21) of two residents reviewed for resident concerns. The facility census was 53.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, observation, self-reported incident (SRI) review and facility policy review, the facility failed to ensure residents were free from misappropriation. This affected five Residents (#20, #35, #46, #54, and #55) out of six residents reviewed for misappropriation. The facility census was 53.

Inspectors wroteBased on record review, interviews, review of a grievance form, and facility policy review, the facility failed to ensure that care was provided in a manner that maintained the resident's dignity and honored the resident's right to be informed of and refuse treatment. This failure affected one resident (Resident #20) of three residents reviewed for resident rights. The facility census was 53.

Inspectors wroteBased on record review, interview, review of a grievance form and facility policy review, the facility failed to ensure treatments were provided in accordance with professional standards and failed to obtain a physician's order prior to administering a topical treatment. This resulted in vinegar being applied to Resident #20 without a physician's order and against the resident's expressed refusal. This deficient practice affected one (Resident #20) of three residents reviewed for physician-ordered treatments. The facility census was 53.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure labs were obtained as ordered for Resident #5. This affected one resident (#5) out of five residents reviewed for unnecessary medications/labs. The facility census was 50.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice or account for experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of Resident #52's post-traumatic stress disorder (PTSD). This affected one resident (#52) of two residents reviewed for trauma informed care. The facility census was 50.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #43 had adaptive equipment as ordered when eating. This affected one resident (#43) out of one resident reviewed for adaptive equipment when eating. This had the potential to affect seven residents (#5, #10, #11, #17, #30, #32, and #43) that had orders for adaptive equipment while eating. The facility census was 50.

Inspectors wroteBased on observation, interview, and review of facility documents, the facility failed to ensure they had a three-day emergency supply of food as required. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54.

Inspectors wroteBased on observation, interviews, review of facility records and review of facility policy, the facility failed to ensure the low temperature dish machine was being appropriately monitored for levels of chemical sanitizer, and the kitchen was clean and sanitary. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54.

Inspectors wroteBased on record review, review of psychotropic medication information, facility policy review and interview, the facility failed to prevent a significant medication error for Resident #26 when the resident's psychotropic medication, for reducing risk of recurrent suicidal behavior with schizophrenia was not administered as ordered by the physician from 11/20/23 until 12/06/23. The facility also failed to ensure the physician was notified timely that the medication was unavailable for administration. Actual Harm occurred on 12/07/23 when Resident #26 was admitted to the hospital with psychosis (having increased behaviors and hallucinations), suicidal ideations, threatening to kill herself and slit her throat with a knife as a result of the missed doses of the psychotropic medication, Clozapine. This affected one resident (#26) of four residents reviewed for medication administration. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #4 was provided a reasonable accommodation to enter the facility and did not ensure Resident #50's wheelchair was serviced and repaired in a timely manner. This affected two residents (Residents #4 and #50) of two residents reviewed for accommodation of needs.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one resident (Resident #34) of eight residents reviewed for elopement care plans.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident #41's bowel pattern was effectively managed. This affected one resident (Resident #41) of two residents reviewed for constipation.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #39 received her medications consistently per physician orders. This affected one resident (Resident #39) of eight residents reviewed for pharmacy services.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident #31's insulin was dated after it was opened. This affected one resident (Resident #31) out of four residents (Resident #5, #28, #31, #39) that received insulin on the north cart two.

Inspectors wroteBased on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to local authorities. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. [...]

Inspectors wroteBased on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to the State Agency as required. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. [...]

Inspectors wroteBased on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement their abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to ensure adequate monitoring of the alleged resident perpetrator, thoroughly investigate the allegation and report the allegation to law enforcement and the State Agency. [...]

Inspectors wroteBased on medical record review, staff interviews, review of facility policies and procedures, and facility Self-Reported Incident (SRI) history, the facility administration failed to ensure facility abuse prevention policies were implemented and appropriate measures were taken in response to an allegation of sexual abuse involving Resident #38. The administrative failure resulted in incidents of Immediate Jeopardy at Data Tags F607, F608, F609, and F610 for not implementing the facility abuse policy, reporting the allegation to local authorities, notifying the State Agency, ensuring adequate monitoring of the alleged resident perpetrator (Resident #47), and thoroughly investigating the allegation. This affected one (Resident #38) of five residents reviewed relative to investigations of physical or sexual abuse and had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure Quality Assessment and Assurance (QAA) meetings occurred quarterly. This had to the potential to affect all residents. The facility census was 46.

Inspectors wroteBased on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This affected one (#38) of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46.

Inspectors wroteBased on observation and interview, the facility failed to ensure bread stored in the kitchen was not expired and free from mold. This had the potential to affect all residents except Resident #25 who received nothing by mouth. The facility census was 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #18's physician was notified when the resident was found with alcohol in his room on two instances. This affected one of three residents reviewed for physician notification. The census was 46.

Inspectors wroteBased on observation and interview the facility failed to maintain a homelike environment. This affected one (Resident #36) of 46 residents reviewed for environmental concerns. The facility also failed to maintain ambient temperatures within 71 and 81 degrees Fahrenheit (F) on the C wing on the South side hall. This affected two (Residents #14 and #43) of eight residents who resided on the C wing of the South side hall.

Inspectors wroteBased on interview, review of the medical record, review of a personnel file, and review of the abuse policy, the facility failed to protect a resident with impaired judgment and impulse control deficits from a sexual relationship with an employee. This affected one (Resident #47) of five residents reviewed for abuse. The facility census was 46.

Inspectors wroteBased on record review, observation, and interview the facility failed to develop a smoking care plan for Resident #3 and revise Resident #18 's care plan regarding alcohol use. This affected two (Residents #3 and #18) of 16 residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative programing to maintain residents' abilities for activities of daily living (ADL) and/or ambulation following therapy. This affected two (Residents #17 and #38) of two residents reviewed for ADLS. The facility census was 46 residents.