McNaughten Pointe Nursing and Rehab

Inspectors wroteBased on medical record reviews, observation, and staff interview, the facility failed to ensure residents' medications were not prepared and removed from the original packaging prior to time of medication administration. This affected eight (Residents #3, #4, #5, #6, #7, #8, #9, and #11) of the eight residents reviewed for medication administration. The facility census was 122.

Inspectors wroteBased on record review and interview, the facility failed to ensure the practitioner was timely notified of ongoing symptoms of nausea and holding of tube feeding administration for Resident #118. This affected one (Resident #118) of three residents reviewed for tube feeding management. The facility census was 116.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure proper incontinence care was completed for Resident #40. This affected one of four residents reviewed for incontinence care (Resident #15, #25, #20 #10). The census was 118.

Inspectors wroteBased on interview, record review, and facility policy, the facility failed to ensure physician-ordered wound care treatments were accurately followed. This affected one (Resident #28) out of four residents reviewed for pressure injuries. The facility census was 112.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to complete a thorough investigation and root cause analysis regarding falls for Resident #59 and failed to ensure adequate supervision, a thorough investigation and root cause analysis were completed for Resident #92 who fell while on an unknown (to facility staff) leave of absence by himself. This affected two residents (#59 and #92) out of three residents reviewed for accidents. The facility census was 112.

Inspectors wroteBased on record review, staff interview, and facility policy, the facility failed to obtain cultures and sensitivities prior to administering antibiotics for multiple episodes of urinary tract infections (UTIs) for Resident #36. This affected one (Resident #36) of three residents reviewed for UTIs. The facility census was 112.

Inspectors wroteBased on interview, record review, and review of the American Nurse's Association standards of professional nursing practice, the facility failed to ensure specified parameters were obtained and recorded during medication administration. This affected one resident (#121) of four residents reviewed for medication administration. The facility census was 117.

Inspectors wroteBased on record review, review of resident council minutes, review of audio/video footage, observation and interview the facility failed to ensure a resident was afforded privacy and dignity during care. This affected one resident (#46) of four residents reviewed for dignity. The facility census was 126.

Inspectors wroteBased on interview, review of audio/video footage and review of Centers for Disease Control Guidelines for Enhanced Barrier Precautions, the facility failed to ensure infection control procedures were implemented to prevent the spread of infection. This affected one Resident (Resident #46) of four residents reviewed for infection control. The facility census was 126.

Inspectors wroteBased on medical record review and staff interview, the facility failed to offer/complete therapy orders as expected. This affected one (Resident #64) of three resident medical records reviewed. The census was 125. Findings Include: Resident #64 was admitted to the facility on [DATE]. Her diagnoses were end stage renal disease, dependence on renal dialysis, type II diabetes, hypertensive heart and chronic kidney disease, anemia, congestive heart failure, hyperlipidemia, mild cognitive impairment, insomnia, anxiety disorder, age related nuclear cataract, macular degeneration, and hyperkalemia. Review of her minimum data set (MDS) assessment, dated 08/13/24, revealed she had a mild cognitive impairment. Review of Resident #64 physician orders, dated 10/15/24, revealed she was ordered physical therapy three to five times per week, for 30 days. [...]

Inspectors wroteBased on medical record review, review of hospital records, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to provide timely and effective pain management as well as adequately monitor resident pain. Actual harm occurred on 01/11/24 when Resident #65 fell, complained of pain to her right ankle, was not provided effective pain management, and was subsequently unable to get out of bed on 01/12/24 due to increased pain associated with the fall. The resident was transferred to the hospital on [DATE] at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. The resident required Oxycodone-Acetaminophen for pain. [...]

Inspectors wroteBased on medical record review, review of hospital records, staff and resident interview, review of facility policy, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to appropriately obtain consent and timely administer a flu and pneumococcal immunizations. Actual harm occurred on 02/29/24, when Resident #104 was diagnosed with pneumonia and was hospitalized for ten days for treatment including intravenous antibiotic therapy. The resident's representative gave permission for the resident to receive the pneumococcal vaccination on 02/01/24 (admission); however, the facility failed to administer the vaccination to the resident. This affected two (Residents #89 and #104) of five residents reviewed for immunizations. The facility census was 117.

Inspectors wroteBased on review of medication storage refrigerator daily temperature logs, observation, staff interview, and facility policy review, the facility failed to ensure medication storage refrigerators were maintained at an appropriate temperature and the temperature was routinely monitored. This affected one (South Unit) medication storage room out of three medication storage rooms in the facility and had the potential to affect all 25 residents (#1, #4, #5, #6, #8, #9, #11, #12, #13, #15, #19, #20, #38, #39, #56, #57, #59, #64, #78, #85, #87, #91, #92, #98, and #108) who received medications from the South Unit medication storage room. The census was 117.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of meal choice sheets, the facility failed to ensure residents were consistently offered meals according to their choices and preferences. This affected two (Residents #34 and #46) out of two residents reviewed for food choices and had the potential to affect all eight Residents (#33, #34, #46, #52, #89, #95, #97, #107) living on the North Hall who receive meals from the kitchen. The census was 117.

Inspectors wroteBased on observations, resident interview and staff interviews, the facility failed to ensure a homelike environment was provided for two Residents (#8 and #9) of two reviewed for homelike environment. Facility census was 117.

Inspectors wroteBased on resident interview, staff interviews, and record review ,the facility failed to ensure care conferences were held with members of the interdisciplinary team including resident participation. This affected two Residents (#57 and #64) of three reviewed for care conferences. Facility census was 117.

Inspectors wroteBased on observations, resident and staff interviews and record review, facility failed to ensure a resident with hand contracture's was provided with nail trimming and care. This affected one Resident (#8) of one reviewed for nail care for dependent residents. Facility census was 117.

Inspectors wroteBased on record review, review of skin grid assessments, review of the wound Certified Nurse Practitioner (CNP) notes, review of an After Visit Summary, staff interviews, and facility policy review, the facility failed to complete timely and accurate skin grid assessments, implement treatment changes timely, and follow up on the wound CNP recommendations timely for one resident (Resident #71). The facility also failed to follow up on discharge recommendations as indicated in the After Visit Summary following a hospitalization for one resident (Resident #71). This affected one resident (Resident #71) of one reviewed for non-pressure skin care. The facility census was 117.

Inspectors wroteBased on record reviews, interviews, observations, and facility policies, the facility failed to ensure accurate and timely wound assessments and care was provided for three residents (#51, #71, and #89) out of four residents reviewed for wounds. The facility census was 117.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to ensure fall interventions were implemented in a timely manner. This affected one (Resident #85) out of two residents reviewed for falls. The census was 117.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure ventilator setting checks were completed as ordered. This affected one (Resident #71) out of four residents reviewed for respiratory care. The facility also failed to ensure respiratory equipment was clean and changed as ordered. This affected one (Resident #83) out of four residents reviewed for respiratory care. The census was 117.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #48) out of five residents reviewed for unnecessary medications. The census was 117.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy and procedure, the facility failed to maintain infection control, related to personal protective equipment (PPE) use, proper hand hygiene, and glove use. This affected two residents (Resident #67 and Resident #220) with the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor Resident #22, Resident #38, Resident #59, Resident #80, and Resident #102's preferences in getting in and out of bed. This affected five (Resident #22, Resident #38, Resident #59, Resident #80, and Resident #102's ) of five residents reviewed for choices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #52 and Resident #59 received sufficient bathing assistance, Resident #3 and Resident #59 received assistance with nail care, Resident #71 received assistance with dressing, Resident #119 received assistance with hair washing, and Resident #21 received assistance with personal hygiene. This affected six residents (Resident #3, Resident #21, Resident #52, Resident #53, Resident #59, and Resident #118) of seven residents reviewed for activities of daily living (ADLs) care.

Inspectors wroteBased on interview, observation, review of activity calendar, and record review, the facility failed to provide activities based on the resident preferences and comprehensive assessments. This affected six residents (Resident #12, Resident #22, Resident #66, Resident #80, Resident #102, and Resident #118) of seven residents reviewed for activities.

Inspectors wroteBased on record review, observation, staff interview, resident interview, and facility policy and procedure review, the facility failed to ensure Resident #25 and #44's oxygen tubing was dated or changed per physician orders, failed to ensure Resident #44's respiratory medications were available and able to be administered per physician orders, and failed to ensure a Ambu breathing bag was placed in Resident #66's room. This affected two residents (Resident #25 and Resident #44) out of two residents reviewed for oxygen therapy, and one Resident (Resident #66) out of two residents reviewed for respiratory care.

Inspectors wroteBased on staff interview, observation, and facility policy review, the facility failed to food was properly stored. This had the potential to affect 85 residents who received meals from the kitchen, as 31 residents in the facility received nothing by mouth. The facility census was 116.

Inspectors wroteBased on medical record review, staff interview, review of infection control logs, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study, and facility policy review, the facility failed to provide adequate justification for the use of antibiotics as a treatment measure for COVID-19. This affected 13 residents (#11, #13, #15, #24, #33, #34, #43, #59, #224, #225, #226, #227, and #228) out of 31 residents who tested positive for COVID-19 from December 2021 through February 2022.

Inspectors wroteBased on staff interview, resident interview, medical record review, and facility policy review, the facility failed to accurately reflect Resident #21 and Resident #119's chosen advanced directives in the residents' medical records. This affected two residents (Resident #21 and Resident #119) of two residents reviewed for advanced directives.

Inspectors wroteBased on staff interview, resident interview, observation, medical record review, and facility policy review, the facility failed to assist Resident #57 with her communication needs due to her hearing impairment. This affected one resident (#57) of three resident reviewed for communication/sensory needs.

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure range of motion was provided for Resident #118 who had impairment to her upper extremities, and failed to ensure Resident #3's splint devices were in place as ordered. This affected two residents (Resident #3 and Resident #118) out of seven reviewed for range of motion.

Inspectors wroteBased on interview and record review, the failed to ensure Resident #29's urinary tract infection (UTI) was identified and treated promptly. This affected of one resident (Resident #29) of two residents reviewed for UTI's.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure Resident #80's peripherally inserted central (PICC) line dressing was changed before it was charted as completed in the Treatment Adminstration Record (TAR). This affected of one resident (Resident #80) one reviewed for PICC line dressings.

Inspectors wroteBased on record review, interview, and observation, the facility failed to monitor for psychotropic side effects and provide planned behavioral health interventions for Residents #29. This affected one resident (Resident #29) of two residents reviewed for mood and behavior.

Inspectors wroteBased on staff interview, resident interview, observation, medical record review, and facility policy review, the facility failed to ensure medication was secured at all times. This had the potential to affect two residents (Resident #23 and Resident #58) of two residents reviewed for medication storage.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure labs were drawn for Resident #76 and Resident #118. This affected two residents (Resident #76 and Resident #118) out of six residents reviewed for labs.