Mission Point Health Campus of Jackson

Inspectors wroteBased on observations, interviews, record reviews, and 2 (R16, R55) of 16 sampled residents, the facility failed to provide palatable food products affecting 46 residents who consume food, resulting in the increased likelihood for residents decreased food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (1) effectively clean food service equipment, (2) effectively date mark all potentially hazardous ready-to-eat food products, and (3) label and date all food products affecting 46 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 46 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a wound care program, that included weekly wound care assessments and treatments in five residents (R2, R5, R16, R29, R46) of five residents investigated for pressure ulcers. Findings IncludeResident #2 (R2) Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of cerebral infarction due to unspecific occlusion or stenosis of the left middle cerebral artery, hemiplegia and hemiparesis on affecting right dominate side, aphasia, dysphagia, and protein- calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure there was Physician oversight and orders for care provided in three residents (R2, R5 and R16) out of five residents. Finding IncludeResident #2 (R2) Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of cerebral infarction due to unspecific occlusion or stenosis of the left middle cerebral artery, hemiplegia and hemiparesis on affecting right dominate side, aphasia, dysphagia, and protein- calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 needed maximum assistance with showering and personal care. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to maintain Dignity in one (R31) of 16 residents when yelling out for help. Findings IncludeResident #31 (R31)Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely Notice of Medicare Non-Coverage for one (R37) of four reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and document evidence of prompt resolution to a grievance for missing personal items of one (resident #16) out of one resident reviewed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive care plan for three residents (#16,#31,#40) of 16 residents reviewed for care plan development and implementation. Resident #31 (R31) Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update/implement revisions for one resident (resident #46) and failed to ensure one resident (resident #7) along with resident #7's legal representative was afforded the opportunity to participate resident #7's care conference.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide person centered care to two dependent residents (R31, R55) out of three residents investigated for ALD's. Findings Include Resident #31 (R31) Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/01/2026 at 8: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide meaningful activities to one resident (R31) out of one resident investigated. Findings IncludeResident #31 (R31)Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a significant weight loss for one resident (resident 5) of 2 reviewed from a total sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Physician Orders for enteral (tube) feeding and accurately document enteral feeding acceptance for one (R1) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for two residents (#5, #40) out of three resident's review for dental services.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R1) of 16 reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the resident call system for 2 (R21, R55) of 16 sampled residents affecting 2 residents, resulting in the increased likelihood for resident negative outcomes related to delayed and/or no emergency response.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily nurse staffing information was accurately posted for each shift in accordance with State Operations Manual, Appendix PP.

Inspectors wroteBased on interview and record review, the facility failed to treat two (R202, R204) of five residents reviewed with dignity and respect.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to: (1) effectively clean and maintain food service equipment, and (2) date mark all potentially hazardous ready-to-eat food products effecting 39 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on observations, interviews, record reviews, 1 (#5) non-sampled resident, and 5 (#21, #35, #145, #146, #243) of 12 sampled residents the facility failed to provide palatable food products effecting 39 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper personal protective equipment (PPE) use for COVID-19 transmission-based precautions in one (R145) of two reviewed and failed to ensure proper disinfection of items for two (R145 and R20) of three reviewed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan with necessary healthcare information for one (R145) of 12 reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for three (Resident #20, #21, and #35) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide a duration of use for as needed (PRN) medication for one (Resident #20) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when five medication errors were observed from a total of 29 opportunities for two residents (R20 and R30) of three reviewed resulting in a medication error rate of 17.24%.

Inspectors wroteThis citation pertains to intake #MI00146888 Based on interview and record review, the facility failed to arrange and provide transportation to a medical appointment for one (R1) out of three residents reviewed resulting in a missed appointment and the potential for delay of care.

Inspectors wroteThis citation pertains to Intakes MI00145676 and MI00145685. Based on interview and record review the facility failed to permit a resident to return to the facility after stabilization following emergency transport to the hospital for one resident (R214) of three residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide a written reason for transfer/discharge for two residents (Resident #212, #214) of three reviewed for transfer/discharge, resulting in residents and/or responsible parties not being informed, in writing, of the reason for transfers/discharges.

Inspectors wroteThis citation pertains to Intake MI00145685 Based on interview and record review the facility failed to administer medication as ordered for one resident (R214) of three residents reviewed potentially resulting in a relapse and escalation of psychologically disturbed behaviors. Findings Include: Review of the electronic medical record (EMR) revealed that R214 was admitted to the facility 7/9/24 with a pertinent diagnosis of Unspecified Dementia, Severe, with Mood Disturbance (a condition that affects thinking, behavior, and the ability to perform everyday tasks). Review of the admission Assessment titled Admission/readmission Assessment dated 7/9/2024, reflected the finding that resident had placed himself on the floor and was crawling around speaking to people . who are not there. [...]

Inspectors wroteThis citation pertains to intake MI00142852. Based on interview and record review, the facility failed to ensure freedom from physical restraints for one (Resident #1) of three reviewed for restraints.

Inspectors wroteThis citation pertains to intake MI00142852. Based on interview and record review, the facility failed to report an allegation of abuse to the Nursing Home Administrator (NHA) and State Agency timely for one (Resident #1) of three reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively date and label food products, and (2) maintain the walk-in cooler refrigeration unit effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) detailing estimated charges of continued services to 2 (Resident #25 and #235) of 3 reviewed for Beneficiary Notification, resulting in the potential for the resident and/or responsible party to be uninformed of the potential charges for continued stay and services at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #9 and #17) of 12 residents reviewed resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise care plans for 1 resident (#3) receiving hospice services and 1 residents (#9) using compression stockings of 12 residents reviewed for care plan revision, resulting in the potential of unmet care needs. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assist with activities of daily living (ADLs) for one (Resident #4) of four residents reviewed for ADL care completion, resulting in missed showers and unmet care needs with the potential for a decline in emotional and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain updated physician's orders for oxygen therapy based on resident need/usage, complete routine monitoring of oxygen saturation levels, and complete thorough respiratory assessments for 1 (Resident #9) of 2 residents reviewed for respiratory care, resulting in the potential for respiratory complications.

Inspectors wroteBased on interview and record review the facility failed to ensure medication regimen irregularities were reviewed and acted upon for two (Resident #19 and #21) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label an open bottle of tuberculin and dispose of an expired bottle of tuberculin in two of three medication rooms reviewed for Medication Storage and Labeling, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 40 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice services for one resident (#3) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely consent for and administration of the influenza immunization for two (Resident #19 and #23) of five reviewed for immunizations, resulting in the potential for influenza infection and complications.

Inspectors wroteThis citation pertains to intake MI00140243. Based on interview and record review, the facility failed to facilitate a safe discharge for one (Resident #3) of three reviewed for discharge, resulting in Resident #3 being discharged from the facility, on two separate occasions, without the recommended equipment or services to ensure a safe transition of care.

Inspectors wroteThis citation pertains to intake number MI00140818. Based on interview and record review the facility failed to identify injury of unknown origin for one out of three residents (Resident #1), who had multiple facial abrasions, resulting in no facility investigation to identify if the origin of the injuries was the result of physical abuse/harm by a perpetrator, who continued to have access to residents, was the root cause of the multiple facial abrasions. Findings Included: Resident #1 (R1) no longer resided at the facility at the time of the onsite investigation. Per the facility face sheet R1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Record review of a confidential document and source dated 10/31/2023, revealed R1 was transferred to the hospital on [DATE] for low blood pressure. [...]

Inspectors wroteThis citation pertains to intake MI00140359. Based on interview and record review, the facility failed to prevent and treat pressure ulcers, in 2 of 3 residents reviewed for pressure ulcers (Resident #1 & #2), resulting in worsening of pressure ulcers (Resident #1), multiple facility acquired pressure ulcers (Resident #1) and pain (Resident #2).