Five Points Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to and the facility made prompt efforts to resolve grievances the resident may have respond for 6 of 11 anonymous residents reviewed for resident rights. The facility failed to provide or demonstrate responses, actions, and rationale taken regarding resident concerns with laundry not being delivered, being delivered incorrectly, and missing items. This failure could place residents at risk of feeling unheard, experiencing feelings of anger and frustration, as well as a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including the procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 4 of 4 medication carts reviewed for pharmacy services. The facility failed to ensure the Controlled Drugs Count Record on 4 medication carts for shift-to-shift narcotic counts did not have multiple blanks which indicated the narcotic count was not completed at shift change. This failure could result in narcotics being misappropriated from the facility which could result in ineffective treatment resulting in exacerbation of residents' disease process.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 18 residents (Resident #84) reviewed for baseline care plans. The facility failed to ensure Resident #84's baseline care plan reflected the resident's prescribed anticoagulant medication, Eliquis, including the need for monitoring related to anticoagulant use. This failure could result in staff not being aware of critical medication related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for medication administration. The facility failed to ensure Resident #1's opioid pain medication was refilled timely. This failure could place residents at risk of increased pain and/or diminished quality of life. Findings Included:Record review of Resident #1's admission record dated 03/09/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 02/07/26. She had diagnoses that included, but were not limited to, chronic pain syndrome and angina pectoris unspecified (chest pain). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment remained free from accidents as was possible and each resident received adequate supervision and assistance devised to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents, hazards and supervision. The facility failed to ensure Resident #1 did not elope from the facility when Resident #1 left the facility in the middle of the night, without anyone knowledge, and ended up 0.4 miles from the facility trying to obtain a hotel room for the night. The noncompliance was identified as PNC. The IJ began on 12/10/25 when Resident #1 eloped from the facility. The facility had corrected the noncompliance before the investigator entered the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 7 residents reviewed for accuracy of medical records. The facility failed to ensure LVN A documented the correct time Resident #1 and his family were provided with copies of his baseline care plan. The facility failed to ensure LVN A documented the correct time Resident #1's family and doctor were notified of his fall on 05/21/25. The facility failed to ensure RN B documented the times correctly on 3 progress notes in Resident #1's chart on 05/23/25. These failures could place residents at risk of not receiving necessary care/treatment due to inaccurate medical records. Findings Included: [...]

Inspectors wroteBased on observation and record review; it was determined the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, and dispensing, and administration of all drugs and biologicals for 3 of 18 (Resident #39, Resident #65, and Resident #230) and 2 of 4 medication carts (Hall 300and Hall 400) under review. -Resident #39's Lispro had an open date on it of 02/17/2025. -Resident #230's Lantus Solostar Pen had an open date on it of 02/08/2025. -1 bottle of Naproxen 220mg that had an expiration date of 02/2025. -Resident #65's Insulin Lispro with an open date of 02/19/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 4 of 4 medication carts (Hall 100, Hall 200, Hall 300, and Hall 400) and 6 of 18 residents (Resident #27, #32, #47, #176, #228. and #229) reviewed for medication storage. -Medication on bedside table of Resident #32. -Medication cart for Hall 200 revealed 25.5 unidentifiable loose pills in the medication cart drawers. -Medication cart for 400 Hall had 1.5 loose pills in the bottom of the medication cart drawers. -Resident #229's Stiolto Aer 2.5-2.5 had no open date. -Resident #228's Trelegy Ellipta had no open date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 Nourishment Room reviewed for sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerated foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #72) of 19 residents reviewed for DNR orders. Resident #72 had a Full Code Status in active medical orders and on Resident's Face Sheet as well as a Do Not Resuscitate (DNR) form in her health record. This failure could place residents at risk of having their end of life wishes dishonored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents have the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 hallways (Hall 100) that were monitored for personal privacy. A resident information sheet was left in the family area of hallway 100 for a 2-hour period. This failure has the potential to affect residents receiving care in the facility by exposing their personal medical information.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #228) of 19 residents reviewed for baseline care plans. The facility failed to ensure Resident #228's baseline care plan included information related to her diabetes and spinal fracture. This failure could place residents at risk of not receiving correct and/or necessary care/treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #31) of 3 residents reviewed for respiratory care. The facility failed to store Resident #31's nasal cannula properly. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review, 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 and transmission of communicable diseases and infections for 2 of 8 staff (MA E and CNA K) reviewed for resident care -MA E did not perform hand hygiene before donning gloves to administer medicated eye drops to Resident #5. -CNA K did not perform hand hygiene or glove change after performing perineal care and placing a clean brief on Resident #45. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse when on 1/23/25, the ABOM yelled at Resident #2 to get the fuck out of my office. Resident #2, who has Alzheimer's disease, was in front of the ABOM's desk and stroking his penis while asking her if she wanted to fuck. This failure could place residents at risk of mental anguish or emotional distress. This was determined to be PNC as the facility had implemented corrective actions prior to entry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure personal items were properly stored. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #188) of 18 Residents reviewed for comprehensive care plans. -The facility failed to include care plans for Resident #188's use of oxygen therapy. This failure could affect residents receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the following information on a daily basis: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift--registered nurses, licensed practical nurses, or licensed vocational nurses (as defined under state law), certified nurse aides-and resident census for one of one facility reviewed for posted nurse staffing information. The facility failed to post nurse staffing data as required in that it did not include the current date on posting, posting was dated 01/30/2024. This failure could place residents and visitors at risk of not being informed regarding the current day's nurse staffing levels.