Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteBased on observation and interview the facility failed to properly dispose of refuge and maintain cleanliness of the garbage and dumpster area, resulting in the potential harborage of pests. This deficient practice has the potential to affect all 109 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy for one resident (R3) of two residents reviewed for privacy resulting in the resident being exposed during wound care On 8/21/2025 at 11:30 AM, Registered Nurse (RN) S and Certified Nurse Assistant (CNA) R was observed providing wound care to R3's sacrum/coccyx (buttocks) area. RN S did not draw the curtain around R3's bed or close R3's room door which allowed visualization of the R3's exposed body from the hallway. Record review revealed that R3 was initially admitted on [DATE]. R3 had the following diagnosis: type 2 diabetes, COPD, hypertension, generalized anxiety, bipolar disorder, and suicidal ideations. Record review of R3 quarterly Minimum Data Set (MDS) from 7/7/2025 for a Brief Interview for Mental Status (BIMS) revealed R3 was cognitively intact with a score of 15 out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a bed that was appropriate and in good condition for one (R66) of three residents reviewed for reasonable accommodations, resulting in unmet comfort needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident room (R62) of nine residents was in good repair. R62. On 8/25/2025 at 11:23 a.m., R62's room was noted with a loud unpleasant odor. Observed chipped paint and holes in the wall over the bed and a fan hanging near the bed with thick dust particles blowing from the fan. The bathroom was observed with multiple areas of black residue on the wall and behind the toilet. The vent was covered with thick dust particles, holes in the wall near the tissue holder and brown stains and scuff marks on the bathroom door. On 8/25/2025 at approximately 11:30 a.m. during an interview R62 stated, The bathroom is filthy and uncomfortable. I have no control over it. I have to wait until they get to it, I guess. R62 confirmed the facility was aware of the repairs and cleaning needed for a long time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standards of practice for medication administration for one (R91) of three residents when a single-dose medication (eye drop) was unopened and intact at the bedside but signed out on the Medication Administration Record (MAR) as being administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents (R63 and R77) shaves and hair care out of two residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs. R63On 8/19/2025 at approximately 12:37 p.m., R63 was observed sitting in bed with unkempt hair. During an interview R63 reported not receiving assistance with hair care. R63 was asked to recall when hair care was last offered and provided by the staff. R63 stated, Oh, my God, it's been a long time. No one offers to comb my hair. I watch my roommate's hair get combed and not [NAME]. My hair needs to be combed because I have had these braids for a long time. My hair has not been combed, brushed or braided since my Birthday (approximately three months ago). I went out for my birthday on that day. Sometimes I get embarrassed because my hair is not combed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide vision services in a timely manner for one (R104) of two residents review for vision, hearing, and communication, resulting in the inability to utilize glasses to improve vision and the potential for a decline in vision.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate pharmacy services when one (R91) of three residents reviewed for medication administration did not have their eye drops available for administration. On 8/20/25 at 9:37 AM during medication administration for R91, Licensed Practical Nurse (LPN) F said the resident's Cyclosporine 0.05% eye drops were not available for administration. An inspection of the medication cart confirmed R91's Cyclosporine 0.05% eye drops were not in the cart. At this time R91 said, I haven't got those eye drops in a while now, maybe 5 - 6 days. They always say they ain't got them. LPN F reviewed R91's Electronic Health Record and said, I requested the pharmacy to refill these eye drops on 8/15/25 and then someone else requested a refill on 8/18/25. I'll call the pharmacy to see where the eye drops are. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure kitchen equipment was maintained in a safe operating condition, resulting in a potential for a delay in food preparation and the safety to staff preparing food. On 8/20/25 at 12:00 P.M., during an observation in the kitchen the South Bend stove was heavily soiled with accumulated baked on food residue and ash. One of the front gas eyes was coated with layers of a (whitish) unknown substance and was covered with soot which impaired the function of the gas eye of the stove. Staff members using the stove were observed constantly readjusting the gas gauges and repositioned cooking equipment because of non-functioning eyes on the stove. The gauges/knobs were present on the stove but were not calibrated adequately causing the bottom of the pans and fryers to be burnt during preparation of the food. [...]

Inspectors wroteThis citation pertains to intake #MI00150510. Based on observation, interview, and record review the facility failed to assess and monitor one resident (R602) from four residents reviewed for change in condition resulting in lack of monitoring, assessment, and the failure to administer emergency medical care/treatment in a timely manner. The resident subsequently died while in the facility.

Inspectors wroteThis citation pertains to intake MI00146598. Based on observation and interview, the facility failed to provide disposable paper towels, a waste receptacle near a handwashing sink, liners for trash cans, and ensure a shower gurney pad was cleaned and sanitized after use.

Inspectors wroteThis citation pertains to intake MI00147590. Based on interview and record review, the facility failed to provide adequate assessment after an injury for one resident (R105), resulting in missed opportunities to identify the potential latent effects of the injury.

Inspectors wroteThis citation pertains to intake MI00146598. Based on observation, interview, and record review, the facility failed to ensure medications for three residents (R113, R115, and R116) located in a treatment cart were not expired.

Inspectors wroteThis citation pertains to intake MI00143714. Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, maintain equipment in good repair, and safely store food. This deficient practice has the potential to affect all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to intake MI00143714. Based on observation, interview and record review facility failed to maintain a good general repair of the facility with a safe and functional environment for multiple resident rooms/resident equipments and common areas reviewed for physical environment. This deficient practice has the potential to affect the residents living in those room(s)/using the equipment(s) and all residents who use the common areas/elevators with feelings of frustration and dissatisfaction with their living conditions.

Inspectors wroteThis citation pertains to intake MI00145765 and MI00146157 Based on observation interview and record review, the facility failed to ensure an environment free from physical abuse for two residents (R12 and R100) of five residents reviewed for abuse/neglect/mistreatment, resulting in R12 being transferred to the hospital and sustaining soft tissue swelling and hematoma involving the right posterior parietal-occipital scalp and R82 being transferred to the hospital and sustaining peri-orbital ecchymosis and a left eye sub conjuntival hemorrhage.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Preadmission Screening (PAS)/Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs for two residents (R79 and R102) of two residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice for medication administration for two (R101 and R44 ) of four residents reviewed for medication administration resulting in 1) R101's medications left unattended on the breakfast tray and extended/delayed release medications being crushed without an order and 2) R44's medications being unavailable for administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper weight monitoring occurred for two residents (R27 and R71) deemed to be at nutrition risk out of six residents reviewed for nutrition status, resulting in weight changes to go undetected and potentially compromise nutrition status.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove a feeding tube (flexible tube inserted through the abdominal wall to administer liquid nourishment, fluids, and medications) when there was no longer a valid clinical indication for its use in one (R29) of two residents reviewed for feeding tubes resulting in R29 expressing feelings of frustration with the presence of an unused feeding tube along with swelling, redness, and drainage at the insertion site, and leakage through two visible holes/cracks in the tube itself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with 13 errors identified out of 35 opportunities, affecting two residents (R73 and R29) of four residents observed for medication administration, resulting in a medication error rate of 37.1%.

Inspectors wroteBased on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one resident (R48) of one residents reviewed for diagnostics.

Inspectors wroteBased on observation, interview, and record review the facility failed to schedule a physician ordered dental appointment for one of one resident (R71) reviewed for dental services resulting in R71 not being seen by a dentist and potential for dental care needs to go unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that personal protective equipment (PPE) was worn while performing wound care for one resident (R104) out of one resident observed during wound care. Findings Include: During an observation of wound care on 8/7/24 at 10:30 AM, Registered Nurse (RN) B entered R104's room to perform wound care for a Stage lll pressure ulcer (wound with full thickness skin loss) on resident's buttock , no PPE was applied by RN B or the staff assisting with treatment. R104's door had signage warning of enhanced barrier precautions. Record review revealed R104 was admitted into the facility on 4/15/24 with a pertinent diagnosis of Pressure Ulcer (bedsore) to right buttock. According to the Minimum Data Set (MDS) dated [DATE], R104 had impaired cognition and was dependent on most Activities of Daily Living (ADLS). [...]

Inspectors wroteThis citation pertains to intake MI00145584 Based on observation, interview and record review the facility failed to ensure a thorough investigation into an allegation of misappropriation was completed and contact law enforcement for one resident (R13) of one residents reviewed for misappropriation.

Inspectors wroteThis citation pertains to intake MI00141834. Based on observation, interview, and record review, the facility failed to ensure the safe operation of the boiler systems by conducting routine inspections, resulting in inadequate heat to the fourth floor. This deficient practice has the potential to affect all residents, staff, and visitors in the facility who visit the fourth floor.

Inspectors wroteThis citation pertains to Intake MI140933. Based on observation, interview, and record review the facility failed to provide and maintain effective pest control services to prevent an infestation of rodents, resulting in uncomfortable living conditions with the potential of spreading communicable disease. This deficient practice has the potential to affect all the residents in the facility. On 12/4/23 at 10:30 a.m. upon entry into the facility, there was a strong odor of moth balls. The odor was detected throughout the first floor. On 12/4/23 at 10:47 a.m. the Director of Nursing (DON) was queried about the strong odor of moth balls. The DON said the moth balls were put down to deter mice. The DON acknowledged the facility was having a rodent problem. The DON showed a container of bait that was bought by the facility from an on-line product distributor. [...]

Inspectors wroteThis citation pertains to intake MI00139324. Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for two Residents (R102 and R101) out of five residents reviewed for abuse resulting in R102's fractured mandible (jaw bone).

Inspectors wroteThis citation pertains to MI00139324. Based on interview and record review, the facility failed to ensure that an allegation of resident-to-resident abuse was reported to the State Agency for one (R105) of five residents reviewed for abuse resulting in the potential for further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services out of the facility's total census of 119 residents.

Inspectors wroteIn an observation on 8/1/23 at 10:00 a.m., a urine smell was noted on the 2nd floor. A cart overflowing with soiled linen and covered with a sheet sat in the hall near dirty linen room. The linen in the cart was not individually bagged. In an observation on 8/2/23 at 9:41 a.m., a cart with soiled linen sat near resident room on the 2nd floor. The cart was uncovered, and the linen was not individually bagged. In an interview on 8/2/23 at 9:44 a.m., Unit Manager (UM) B reported the soiled linen cart stays in the hall and goes from room to room. UM B then reported the cart is usually covered. In an interview on 8/2/23 at 9:49 a.m., Licensed Practical Nurse (LPN) C reported the soiled linen cart goes room to room. LPN C reported the cart is near the room, so the CNAs don't have to carry soiled linen down the hall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 119 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure that garbage storage area was maintained in sanitary condition resulting in an increased potential for the harborage and feeding of pests.

Inspectors wroteBased on observation and interview the facility failed to ensure that all kitchen equipment is maintained in a safe, and its originally approved operating condition resulting in an increased potential for harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for personal sleeping preferences for one (R46) of 26 residents reviewed for care plans, resulting in the potential for unidentified and unmet resident care needs.

Inspectors wroteBased on interview and record review the facility failed to correctly transcribe a physician's order for one (R38) of three residents reviewed for urinary tract infections (UTI), resulting in ineffective treatment of a urinary tract infection. Findings Include: Record review of R38's face sheet revealed admission into the facility on [DATE] and readmission on [DATE] with a pertinent diagnosis of UTI. According to the Minimum Data Set (MDS) dated [DATE], R38 had intact cognition and required limited to extensive assistance with most Activities of Daily Living (ADLs). Record review of Medication Administration Record (MAR) dated July 1, 2023, to July 31, 2023, documented the following order: Nitrofurantoin Macro crystal Oral Capsule (antibiotic) 100 MG (Nitrofurantoin Macro crystal) Give 1 capsule by mouth two times a day every 7 day(s) for UTI for 7 days. Start Date- 7/26/23 at 5:00 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 12 hours of in-service education was provided for two of five Certified Nurse Assistances (CNA's C and E), resulting in the potential for care performance concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the standards of infection control for proper gloves use and hand hygiene and proper storage or personal resident equipment, resulting in the potential for increased cross-contamination of infection. This deficient practice had the potential to affect all residents within the facility.