Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteThis citation pertains to intake #3073173 & #3071679. Based on observation, interview, and record review, the facility failed to ensure transfers and toileting were completed per the care plan, and ensure staff implement facility policies and procedures for falls in 1 resident (Resident #101) of 4 residents reviewed for accidents/falls, resulting in harm when Resident #101 sustained multiple fractures to her left lower extremity after an unsafe transfer.

Inspectors wroteBased on interview and record review, the facility failed to ensure the proper notifications were made for 4 residents (Resident #101, #102, #104 & #105) of 6 residents reviewed for notifications, resulting in the potential for a delay in care and worsening of medical conditions.

Inspectors wroteThis citation pertains to intake #3071679Based on interview and record review, the facility failed to release medical records to the resident/resident representative in a timely manner for 1 resident (Resident #101), resulting in delayed access to a resident's medical records.

Inspectors wroteThis citation pertains to intake #3073173. Based on interviews and record review the facility failed to ensure timely reporting of an allegation of neglect for 1 resident (Resident #101) of 4 residents reviewed falls, when staff failed to follow Resident #101's care plan interventions for safe transfers, resulting in acute fractures to the resident's left lower leg and ankle.

Inspectors wroteThis citation pertains to intake #3073173 & #3071679. Based on interview and record review, the facility failed to implement care planned interventions for transfers and toileting in 1 resident (Resident #101) of 4 residents reviewed for falls, resulting in Resident #101's fall with multiple fractures to her lower leg following an unsafe transfer.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 3 residents (Resident #102, #104 & #105) reviewed for the provision of nursing services, resulting in medication not administered following physician orders, the lack of assessment, monitoring, and documentation and the potential for the worsening of medical conditions.

Inspectors wroteThis citation pertains to intake #3090808. Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards for 1 resident (Resident #102) of 4 residents reviewed for quality of care, when nursing staff failed to ensure a newly admitted resident received monitoring and treatment for Type 2 diabetes mellitus (chronic high levels of sugar) resulting in missed insulin (medication that regulates blood sugar) doses, lack of blood sugar monitoring and the potential for worsening of health conditions and a delay in treatment.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan in 1 of 17 residents (Resident #36) reviewed for comprehensive care plans, resulting in the potential for unmet medical and nursing needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the appropriate therapeutic diet food textures were provided consistently for 3 (Residents #13, 71, and a confidential informant) of 3 residents reviewed for therapeutic diet food textures resulting in dissatisfaction with food provided, decreased oral intake, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1.) a physician order was in place for dialysis treatments (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) and 2.) post (after) dialysis assessment and monitoring was documented for 1 (Resident #11) of 1 resident reviewed for dialysis care, resulting in an incomplete reflection of the resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) during high-contact resident care activity for 1 (Resident #8) of 4 residents reviewed for EBP, and to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for the spread of infection and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteThis citation pertains to intake MI00150276 Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident mental and psychosocial abuse for 1 (Resident #106) of 4 residents reviewed for abuse, resulting in Resident #106 experiencing mental anguish, intimidation, and fear.

Inspectors wroteThis citation pertains to intake #MI00150233 Based on observation, interview and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent falls with injury for a resident with a history of multiple falls in 1 (Resident #100) of 3 residents reviewed for falls, resulting in Resident #100 falling and sustaining a humerus (bone of the upper arm) fracture and significant pain.

Inspectors wroteThis citation pertains to intake number MI00150233. Based on interview and record review, the facility failed to notify a responsible party of a change in care/condition for 1 of 3 residents (Resident #102) reviewed for notification of change, resulting in the responsible party not participating in medical decisions regarding care and treatment.

Inspectors wroteThis citation pertains to intake #MI00150276 Based on interview and record review, the facility failed to operationalize its abuse policy and procedure for 3 residents (Resident #105, Resident #106 and Resident#107) of 3 residents reviewed for resident-to-resident abuse, resulting in 1.staff not reporting resident to resident observations of abuse to the Nursing Home Administrator immediately, 2. the facility not initiating a thorough investigation 3. the facility not reporting allegations of abuse to the state agency,and the potential for further resident to resident observations of abuse to go unreported and uninvestigated.

Inspectors wroteThis citation pertains to Intake # MI00150276. Based on interview, and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner in 3 of 3 residents (Resident #105, Resident #106 and Resident #107) reviewed for abuse and reporting, resulting in the potential for additional allegations of abuse and to go unreported and delayed investigation.

Inspectors wroteThis citation pertains to intakes MI0015276 Based on interview and record review, the facility failed to investigate an allegation of abuse for 3 residents (Resident #105, Resident #106 and Resident #107) of 3 total residents reviewed for abuse resulting in the potential for the allegation to not be thoroughly investigated and further abuse to occur.

Inspectors wroteThis citation pertains to intake #MI00150276 Based on interview and record review, the facility failed to ensure a referral was made for a level II evaluation (a comprehensive evaluation completed by the local (state mental health authority) for one (Resident #105) of one resident reviewed for PASARR (Preadmission Screening/Annual Resident Review) screenings, resulting in a potential for unmet behavioral health needs.

Inspectors wroteThis citation pertains to intake #MI00150276 Based on interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 3 residents (Resident #105) reviewed for complete documentation, resulting in the lack of proper documentation of evaluation of abusive behaviors.

Inspectors wroteThis citation pertains to intake #MI00148287 Based on interview andrecord review, the facility failed to protect the residents right to be free from resident to resident sexual abuse in 1 of 1 residents (Resident #30) by Resident #58

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents 1 of 66 residents as well as staff, and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents. Findings Include: During a tour of central supply storage, at 2:53 PM on 12/9/24, with Environmental Services Manager (ESM) H, found that raw wood shelving was being used for storage of clean and sanitary supplies. Raw wood was observed with numerous stains, chipping, and pitting in areas. Items observed stored on these shelves were: gauze, oxygen supplies, personal hygiene products. During a tour of the outside storage barn, at 3:00 PM on 12/9/24, it was observed that numerous outer openings were found near the entrance door and front garage door. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide palatable food products in 5 of 7 residents (Resident #8, #9, #4, #12, & #22) reviewed for food palatability, resulting in dissatisfaction with meals and the potential for nutritional decline.

Inspectors wroteBased on interview and record review the facility failed to ensure that an effective training program for abuse prevention for all staff was maintained and monitored for completion, resulting in the potential for decreased resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity and ensure a dignified environment during meal times in 3 of 3 residents (Resident #14, #17, & #60) reviewed for dignity/respect, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on interview and record review the facility failed to update a care plan following a new diagnosis in 1 (Resident #58) of 17 residents reviewed for care plans, resulting in an incomplete depiction of a resident's status and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed consistently apply a positioning device (a brace) for 1 resident (R#55) of 2 residents reviewed for limited range of motion (ROM), resulting in the potential for decreased range of motion, contractures (hardening of the muscles, tendons, and other tissues), and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate personal protective equipment (PPE) was utilized as required when providing care for 2 (Resident #40 and #17) of 6 residents reviewed for infection control practices resulting in the potential for the spread of disease and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a functioning call light for 1 of 2 residents (Resident #39) reviewed for call lights which could potentially result in delayed response and negative resident outcomes.

Inspectors wroteThis citation pertains to intake MI00145713. Based on interview and record review, the facility failed to protect the resident's right to be free from resident to resident sexual abuse in 3 (Resident #101, #103, #104) of 4 residents reviewed for abuse resulting in the potential for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake MI00145713. Based on interview and record review, the facility failed to: 1.) thoroughly investigate an allegation of resident to resident sexual abuse, and 2.) prevent the potential for further resident to resident sexual abuse 1 (Resident #101) of 4 residents reviewed for abuse, resulting in the potential for additional abuse and abuse allegations.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 2 (Resident #103 and Resident #104 ) of 5 residents reviewed for medical records, resulting in inaccurate and incomplete medical records and the potential for facility staff and providers not having all of the pertinent information to care for residents.

Inspectors wroteThis citation pertains to intake MI00140252. Based on interview and record review, the facility failed to provide urinary catheter care per physician orders in 2 of 3 residents (Resident #101 and #103) reviewed for catheter care, resulting in an increased risk of infection and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure anti-depressant medication orders were implemented as directed by the physician in 1 (Resident #21) of 4 residents reviewed during medication administration, resulting in the potential for residents to be unable to attain their highest practicable mental and psychosocial well-being.