Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor laboratory values and ensure the resident representative was involved with treatment decisions for 3 residents (Residents #58, #90, and #16) out of 21 residents reviewed for unnecessary medication. Findings Include;Review of the FDA prescribing information for Clozaril revealed, Severe Neutropenia CLOZARIL treatment has caused severe neutropenia, defined as an absolute neutrophil count (ANC) less than 500/uL. Severe neutropenia can lead to serious infection and death. Recommended Frequency of ANC Testing During CLOZARIL Treatment-Day 1 to Month 6: WeeklyMonth 7 to Month 12: Every 2 weeksMonth 13 and thereafter: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 2 of 21 residents (Resident #15 and #16), reviewed for nursing professional standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 residents (R57, R7 and R13) out of 4 residents reviewed for accidents, had appropriate interventions implemented to avoid accidents. Findings Include:Resident #57 (R57)Review of a Face Sheet reflected R57 admitted to the facility with diagnoses that included Parkinson's disease, dementia and spinal stenosis. During an observation on 5/26/26 at 11:00 AM, Certified Nurse Aide (CNA) F provided incontinent care for R57 without another staff member present to assist with positioning the resident. CNA F was observed rolling R57 away from their body without support at the edge of the bed, placing R57 at risk for rolling off the side of the bed. [...]

Inspectors wroteThis citation pertains to intake 2626738Based on observation, interviews and record review, the facility failed to protect the resident's (R4's) right to be free from physical abuse by another resident (R3), resulting in physical and psychosocial harm to R4.

Inspectors wroteThis citation pertains to intake 2626738Based on observation, interview and record review, the facility failed to ensure it provided a meaningful activity program for cognitively impaired residents living on the locked unit and 2 residents (R3 and R4) out of 7 sampled residents reviewed.

Inspectors wroteThis citation pertains to intake 2626738Based on observation, interview, and record review the facility failed to thoroughly investigate resident-to-resident abuse for two residents (R3 & R4).

Inspectors wroteThis citation pertains to intakes MI00153884 and MI0015408 Based on observation, interview and record review the facility failed to prevent one Resident (R1) of 3 Residents reviewed from leaving the facility unsupervised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for five of six resident's reviewed (Resident #294, Resident #32, Resident #70, Resident #14, and Resident #9) who had been care planned or assessed for the use of a call light.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for treatment and medication administration for 4 residents (Residents #48, #35, #83, and #69) out of 9 residents reviewed for the provision of nursing services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a resident assessment for self-administration of prescription medication for 1 resident (R73), of 1 resident reviewed for self-administration of medication.

Inspectors wroteBased on interview and record review, the facility failed to 1.) implement a physician's order for daily weights, 2.) administer as needed medication for weight increase, and 3.) ensure the provider was notified of weight gain for residents with Congestive Heart Failure (CHF) for 2 residents (Residents #17 and #89) out of 11 residents, reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were transferred following care planned interventions for 2 residents (Residents #66 and #78) out of 3 residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly explain the arbitration agreement and complete paper work accurately for two of three residents ( Resident #58 and Resident #88) reviewed for arbitration.

Inspectors wroteThis citation pertains to intake #MI00147642 and #MI00148721. Based on interview and record review, the facility failed to report alleged resident abuse within the two-hour required timeframe for 4 residents (R101, R102, R103, and R104), of 5 residents reviewed for abuse.

Inspectors wroteThis Citation has two Deficient Practice Statements (DPS) DPS #1 This Citation Refers to Intake Number MI00142983 Based on observation, interview, and record review the facility failed to identify, assess, properly monitor, and treat mental and/or physical changes in condition and failed to accurately and timely document changes for two Residents (Resident #85 (R85) and R76) resulting in admission to an Intensive Care Unit in critical condition for R85 and delay in treatment for R76.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified dining experience for 8 of 11 residents, 7 of the residents including (R70 and R29) were being assisted by staff standing over them and one Resident (R82) watched residents eat for 20 minutes prior to being served his meal, resulting in an undignified dining experience for residents.

Inspectors wroteThis Citation pertains to Intake MI00142041 Based on observation, interview, and record review the facility failed to ensure meaningful Activities were provided to 1 facility residents directly (Resident #53 (R53)) and all facility residents in the S-1 and S-2 memory care units resulting in unengaged cognitively impaired resident not engaged in activities that a reasonable person would partake in to avoid boredom and to seek a sense of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent repeated falls for 1 of 4 residents, Resident #82 (R82) reviewed for falls. The deficient practice resulted in R82 sustaining repeated falls with minor injury over a 60 day period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) safeguard the confidentiality of medical records for 1 of 27 facility residents [R25) and 2) maintain complete, accurate, and timely medical records for 3 of 27 residents (R70, R85, and R98), resulting in inaccurate medical records and delayed entry of vital medical record information by the physician provider, the potential for providers not having an accurate and complete picture of the resident's stay at the facility, the potential for unauthorized access to resident medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified care concerns, respond to deficiencies, and maintain compliance for all residents that resided at the facility. The deficient practices resulted in repeated identified deficiencies from the previous annual survey, and undesired outcomes for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and utilize enhanced barrier precautions for 2 of 3 resident's (Resident #48 and Resident #502) reviewed for and who were currently placed on enhanced barrier precautions.

Inspectors wroteBased on observation and interview, the facility failed to maintain ventilation, resulting in odors and uncirculated air, affecting all residents' in the North Hall's.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nurse Aides had completed a minimum of twelve hours of in-service training annually.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent from the residents' responsible parties prior to administration of the medications for 2 of 5 residents reviewed (R70 and R87), resulting in the potential for the responsible parties not being informed that R70 and R87 were on psychotropic medications, not being informed of the indications for use of the psychotropic medications, the risks and benefits of the use of psychotropic medications, and the opportunity to decline the use of the psychotropic medications prior to administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that Resident #44's room was clean and uncluttered to allow safe access to the bed and oxygen concentrator, resulting in the potential for falls and the inability to provide appropriate oxygen therapy. Findings Include: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Bipolar disorder, heart disease, Chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure. The MDS assessment dated [DATE] indicated the resident was independent with most care and had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement it's abuse and neglect prohibition policy and procedure for 1 resident (R82) out of 14 residents reviewed, resulting in a failure to identify and investigate an allegation of abuse.

Inspectors wroteThe facility provided a copy of the Fall Reduction Policy dated 2/14/02, last revised date 4/2023 for review. The policy reflected, 2. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks .a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . R82 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R82 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (memory and safety impairment), and history of falls. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represented R82 had severe cognitive impairment involving short and long term memory deficits. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered per standards of practice for 3 residents (#'s 60, 93 and 405) reviewed for medication administration, resulting in the lack of nursing presence during medication administration for two residents (#'s 60 and 93) without assessment for self-administration of medication and administering medications outside of the physician prescribed orders for Resident #405, which could lead to adverse effects. Findings Include: Resident #60 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #60 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of brain and ovarian cancer, Alzheimer's Dementia, heart disease, history of falls with vertebral fracture, anxiety, depression, diabetes and lymphedema. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Restorative nursing services for one Resident (#60) of 2 residents reviewed for range of motion, resulting in the potential for a decline in condition. Findings Include: Resident #60 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #60 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of brain and ovarian cancer, Alzheimer's Dementia, heart disease, history of falls with vertebral fracture, anxiety, depression, diabetes and lymphedema. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss and needed assistance with all care. On 4/02/24 at 9:13 AM, Resident #60 was observed sitting in a wheel chair in her room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor weight changes for 1 of 27 residents (Resident #101) reviewed for weight loss. The deficient practice resulted in Resident #101 (R101) sustaining a significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow accepted standards of practice for a peripherally inserted central catheter (PICC line) dressing change for 1 Resident (#405) of 2 reviewed for IV catheters, resulting in a lack of proper hand hygiene, use of a sterile barrier and measurement of the external catheter length, which could result in complications including infection and migration of the catheter. Findings Include: Resident #405 A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #405 revealed an admission date to the facility on 2/1/2024 and readmission on [DATE] with diagnoses: Meningitis, brain abscess, brain and lung cancer, diabetes, chronic kidney disease, history of pulmonary embolism. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure unobstructed access to an oxygen concentrator and provide oxygen humidification for one Resident (#44), resulting in the potential for the resident to receive an inadequate amount of oxygen to meet their needs, and discomfort without humidification, which could lead to adverse effects including respiratory distress. Findings Include: Resident #44 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Bipolar disorder, heart disease, Chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure. The MDS assessment dated [DATE] indicated the resident was independent with most care and had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. [...]

Inspectors wroteThis Citation pertains to Intake MI00142983 Based on interview and record review the facility failed to timely document assessments and findings in the medical record by a medical provider and failed to ensure necessary monitoring, care, and medical treatment was ordered when changes in condition were noted by a Medical Provider but not acted upon for one facility Resident (Resident #85 (R85)) resulting in emergency Intensive Care hospitalization. Findings Include: Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility 8/26/22 and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services for 1 of 27 residents (R98), resulting in R98 not having current up-to-date guardianship documentation.

Inspectors wroteThis Citation Refers to Intake Number MI00142983 Based on interview and record review the facility failed to properly monitor for psychotropic medication side effects and failed to identify and report signs that resulted from medication changes for one Resident (Resident #85 (R85)).

Inspectors wroteBased on observation, interview, and record review the facility failed to publicly post nurse staffing data.

Inspectors wroteThis citation pertains to intake MI00140722. Based on interview, observation, and record review, the facility failed to ensure elopement interventions were implemented for 2 of 3 residents (Resident #54 and Resident #57) reviewed for elopement. This deficient practice placed Resident #54 (R54) and Resident #57 (R57) at risk for elopement when prevention interventions were not in place and monitored.

Inspectors wroteThis citation pertains to intake number MI00140515. Based on observation, interview, and record review, the facility failed to ensure safe transfers with a mechanical lift (per manufactures guidance) and thorough assessment after a fall for 1 of 3 residents (Resident #51) reviewed for falls. This deficient practice resulted in Resident #51 (R51) falling from a mechanical lift with a delay in assessment and treatment for 3 fractures.

Inspectors wroteThis citation pertains to intake number MI00138957. Based on observation, interview, and record review, the facility failed to prevent misappropriation of resident property for 1 (Resident #1) of 3 residents reviewed for misappropriation. This deficient practice resulted in staff removing and taking resident personal property from Resident #1's body after she passed away and the potential for more resident items to be taken.

Inspectors wroteThis citation pertains to MI00136719, MI00137186 and MI00139193. Based on interview and record review, the facility failed to prevent staff to resident abuse for two residents (#5, #7) which could result in further abuse of residents and cause pain, humiliation, embarrassment, fearfulness, frustration, and feelings of being unsafe in the facility based on a reasonable person standard for residents with impaired cognition.