Five Points Nursing & Rehabilitation of College St.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 1 of 7 residents (Resident #1) reviewed for resident rights.1. The facility failed to ensure Resident #1's bed linens were changed several days between 6/30/2026-7/30/2026.2. The facility failed to maintain an adequate supply of clean linen that included bed linens and towels, to ensure resident's bedding could be changed when needed and that clean towels were available for residents' showers and personal care. These failures could place residents at risk for an unclean, unsafe, and uncomfortable environment.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 residents (Resident #1 and Resident #2) reviewed for personal hygiene. 1. The facility failed to provide Resident #1 with 6 scheduled showers between 06/30/2026 and 07/30/2026. 2. The facility failed to provide Resident #2 with 2 scheduled showers on 07/21/2026 and 7/23/2026. These failures could place residents at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents (Resident # 9) reviewed for activities. The facility failed to provide Resident #9 in room activities three times per week from April 2026 through June 18, 2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for residents # 12, # 18 and Confidential Resident # 1 who consumed foods orally from the only kitchen in the facility in that: The facility failed to provide palatable food that was appetizing to residents who complained the food did not taste good, it was too salty and that it was frequently cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure that SNA J sanitized hands between food tray distribution on hallway 200.2. The facility failed to ensure DC M used proper hand hygiene prior to putting on gloves. 3. The facility failed to ensure the [NAME] used proper sanitation when touching kitchen chicken broth jar lid. These deficient practices could place residents at risk for food borne illness. Findings Included: During an observation on initial tour of the kitchen on 06/16/2026 at 11:00 a.m., SNA J failed to sanitize hands between distributing lunch trays to room [ROOM NUMBER] and room # 213. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one facility reviewed for social work services in that:The facility, which was licensed for 130 beds, failed to employ a qualified social worker on a full-time basis since 2/21/2026. This failure could place residents at risk for unmet social services and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 10 residents (Resident #20 and Resident #34) reviewed for resident rights. The facility failed to ensure SNA J knocked on Resident #20 and Resident #34's door when going into the residents' rooms to deliver lunch meal. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one of seven residents (Resident #9) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #9 received in room activity programs and resident preferences of not wanting showers, baths, snacks, and not having family involved with care discussions. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 60 and Resident # 78) reviewed for ADL care. The facility failed to ensure Resident #60's nails were cleaned on 06/16/2026. The facility failed to ensure Resident # 78's facial hair on chin, under chin, and above upper lip was removed on 06/16/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two of eight (Resident #1 and Resident #2) residents reviewed for quality of care. 1. The facility failed to provide urostomy (a surgical procedure that creates an alternate pathway for urine to leave the body though an artificial opening on the abdomen) bags for Resident #1.2. The facility failed to provide tracheostomy (a surgical hole created through the neck to the trachea to assist with breathing) inner cannulas (a removable tube within a tracheostomy that helps keep the airway clear of mucus and debris) and Enemeez (a docusate sodium mini enema used to treat constipation) for Resident #2. [...]

Inspectors wroteBased on interview and record review the facility failed to provide care, consistent with professional standards of practice, to heal pressure injuries for one resident (Resident #2) out of four residents reviewed for pressure injuries. The facility failed to assess the wound to Resident #2's sacrum (the triangular area at the base of the spine fused between the hips) and acquire orders upon admission on [DATE] until 04/08/2026. This failure could place residents at risk of worsening wounds, infections and pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1's fall mat was in place, and the bed was in low position on 02/12/2026 at approximately 7:00 a.m., when he was found lying on the floor. The noncompliance was identified as PNC. The noncompliance began on 02/12/2026 and ended on 02/12/2026. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for falls with the possibility of injury, including fractures.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 3 residents. The facility failed, on 12/08/25, to ensure two staff members assisted Resident #2 off the toilet and onto her wheelchair. Resident #2 fell and hit her knee on the toilet paper dispenser when CNA E transferred her off the toilet alone. Resident complained of pain. On 12/10/25 an x-ray revealed Resident #2 had a broken femur, was sent to the hospital and had surgery. An Immediate Jeopardy (IJ) was identified on 12/21/2025. The IJ template was provided to the facility on [DATE] at 2:07 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of two residents reviewed for medication administration, in that: The facility failed to ensure they administered Resident #1 a one-time order, dated 12/10/25, of 500 ml of Sodium Chloride 0.9%. Resident #1 instead received approximately 900 ml of Sodium Chloride 0.9%. Resident #1 was sent to the hospital for SOB, and returned the same day with a diagnosis of pneumonia, no fluid overload. The failure placed residents at risk for fluid overload, shortness of breath, blood pressure issues, physical injury to organ failure.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on from 10/03/2025 thru 10/09/2025 to a skin tear on Resident #1's shin on the right lower leg. This failure could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keysfor 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to prevent Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #1) reviewed for abuse/neglect. The facility failed to ensure Resident #1 was not neglected by not checking on Resident #1 from 2:40pm - 4:40pm on 08/26/2025. Resident #1 was found outside with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure each resident received adequate supervision for 1 of 8 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 had adequate supervision or was checked on for over two hours as he was found outside on 08/26/25 with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. [...]

Inspectors wroteBased on observation and interview, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 (08/26/2025, 08/27/2025, 08/28/2025) of 4 days reviewed for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 08/26/2025, 08/27/2025, and 08/28/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 call light was within reach on 06/03/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 6 residents (Resident #1 and Resident #2) reviewed for bathing. The facility failed to provide showers to Resident #1 and Resident #2 in compliance with her shower schedule. This deficient practice could place residents at risk of decline in skin integrity and overall health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on 04/30/2025, 05/03/2025, and 05/05/2025 to a pressure ulcer on Resident #1's left heel. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for fiscal year 2025 for the first quarter (October 1, 2024, to December 31, 2024) reviewed for one of one facility administration reviewed. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 9 of 23 residents (Resident # 6, #15, #17, # 24, # 28, #45, # 66, #72, #76) reviewed for ADL care. The facility failed to provide showers as scheduled for Residents # 6, #15, #17, # 24, # 28, #45, # 66, #72, and #76. This failure could place residents who were unable to carry out ADLs independently, at risk of skin breakdown, pain, and infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 9 (Residents #6, #11, #24,#28, #45, #66, #72, #73, #76) of 20 residents reviewed for sufficient staffing. The facility failed to ensure the facility had sufficient staffing to meet the needs of Residents #6, #11, #24, #28, #45, #66, #72, #73, #76. This failure could place the residents at risk of resident's needs, safety, and psychosocial well-being not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to discard a ham expired 04/16/2025 containing ice particles in the plastic ziplog bag. 2. The facility failed to ensure an opened bag of rolls were properly sealed, labeled, and dated. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choices for one (Resident #48 ) of six residents reviewed for resident rights. The facility failed to promote and facilitate Residents #48's self-determination by not providing the resident with the support needed to get out of bed daily. This failure could place the resident at risk of feelings of depression, lack of self-determination and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 6 residents (Resident #1) reviewed for medical record confidentiality. The facility failed to ensure the ADON kept Resident #1's medical information confidential. This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for two (Resident #14 and Resident #48) of six residents reviewed for comprehensive care plans. 1. The facility included anticoagulant therapy on the residents' care plans without a recommendation or order for such. 2. The facility failed to include ordered antiplatelet therapy on the residents' care plans. This failure could affect residents by placing them at risk of not receiving appropriate interventions and care to meet their current needs.

Inspectors wroteBased on observations, interviews, 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 of 1 medication room reviewed for pharmacy services. The facility failed to ensure an expired medication was removed from the medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose and possible exacerbation of health conditions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were received and acted upon for 1 (Resident # 58) of 4 residents reviewed for drug regimen review. The facility failed to follow up on pharmacy consultant recommendations dated 1/28/25 for Resident # 58. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration.

Inspectors wroteBased on observations, interviews, and record review the facility failed to properly store, label, and/or secure medications and biologicals for 1 of 2 medication carts. The facility failed to ensure the medication aide cart for A hall was locked when unattended by CMA J on [DATE] from 07:15 AM until 07:43 AM. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medication, needles, and other biologicals. These failures could also place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose and possible exacerbation of health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 1 (Resident #13) of 15 residents reviewed for infection control. The facility failed to ensure TN, MDSC B, DON performed appropriate Enhanced Barrier Precaution steps while providing wound care to Resident #13. This deficient practice could place residents in the facility at risk for infections that could lead to other facility-acquired infections, delayed wound healing, sepsis, and hospitalizations.

Inspectors wroteBased on observations and interviews, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; and the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 1 of 1 days reviewed for staffing postings. The facility failed to post current daily staffing information on 04/22/2025. This failure could place the residents, families, and visitors at risk of not having access to information regarding the number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with a current accurate facility assessment for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility failed to ensure sufficient staff to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility Administration failed to ensure an effective system to monitor for adequate staffing to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. Residents #4 and #7 needed care including incontinent care and repositioning on 1/23/2025 for an unknown amount of time. 2. The facility Administration failed to ensure an effective monitoring system for adequate staffing to provide showers to Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11 in compliance with their shower schedules. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene for nine (Resident #1, #2, #3, #4 #5, #6, #7, #8 and #11) of eleven residents reviewed for ADLs. The facility failed to provide showers to Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 2 (100/200 hall cart) medication carts reviewed for pharmacy services. The facility failed when RN A did not ensure the 100/200 medication carts was locked and medications were secured and not accessible to other staff, residents, or visitors when not in use on 10/16/2024. These failures could place residents at risk of injury and result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level.