Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteResident #12 Review of an admission Record revealed Resident #12 was a female, with pertinent diagnoses which included heart failure, diabetes, chronic pain, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 5/1/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Further review of Resident #12's MDS assessment, dated 5/1/25, revealed she was frequently incontinent of bowel and bladder. In an interview on 6/23/25 at 10:49 AM, Resident #12 reported long wait times for care. Resident #12 reported staff will often respond to her call light, deactivate the light and say they will be back shortly, then not return which forces her to activate the call light all over again. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received care in accordance with professional standards of practice in 1 (Resident #44) of 15 residents reviewed for quality of care, resulting in lack of monitoring and treatment for Resident #44's Jackson Pratt (JP) drain (a surgical suction drain that draws fluid from a wound to help recover from surgery; the bulb pulls the fluid out when it is squeezed) and the potential for blockage and rehospitalization for infection.

Inspectors wroteThis citation pertains to Intake #MI00147517 Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 2 of 5 residents (Resident #109 & #110) reviewed for misappropriation of property, when a licensed nurse diverted controlled medications for personal use, resulting in the potential for all residents in the facility to be affected.

Inspectors wroteThis citation pertains to Intake #MI00147517 Based on interview, and record review, the facility failed to maintain professional standards of nursing in 2 of 5 residents (Resident #109 & #110) reviewed for misappropriation of controlled medication, when licensed nurses falsely witnessed to the destruction of controlled medications, resulting in the diversion of narcotic medications for staff personal use.

Inspectors wroteThis citation pertains to MI00145581. Based on interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 2 residents (Resident #305) reviewed for elopements, resulting in an Immediate Jeopardy when on 6/13/2024 at approximately 8:34 PM, Resident #305, who was cognitively impaired exited the facility by facility staff when he was mistaken for a visitor and traveled on foot along a busy road with a speed limit of 40 miles per hour looking for his sister. Resident #305 was found by community members who returned him to facility staff who were searching for him and they brought him back to the facility. This deficient practice placed Resident #305 and other residents identified as at risk for elopement at risk for serious harm, injury, and/or death.

Inspectors wroteThis citation pertains to Intake MI00145186 Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 1 resident (R404) reviewed for medication administration resulting in an Immediate Jeopardy when, beginning on 5/23/2024 at approximately 7:46 AM, R404 was administered another residents medications and was found unresponsive. Resident #404 was hospitalized in the ICU (Intensive Care Unit - provides care and life support for acutely ill/injured patients) on BiPAP (Bilevel Positive Airway Pressure - a device that helps with breathing) with a Narcan drip (a medication used to treat an opioid overdose) and the likelihood of further life-threatening deterioration in his medical condition.

Inspectors wroteThis citation pertains to MI00145186 Based on observation, interview, and record review the facility failed to follow professional standards of practice for nursing for 1 of 18 residents (R404) reviewed for significant medication errors resulting in R404 receiving another resident's medications including opioids, experienced respiratory failure, and sent to the hospital for life-sustaining treatment.

Inspectors wroteThis citation pertains to intake: MI00145580 Based on record review and interview, the facility failed to ensure residents recieved care in accordance with residents needs in 2 of 18 residents (Resident #27 and Resident #406) review for quality of care, resulting in Resident #27 not receiving appropriate assessment and treatment for a injury of unknown origin, and Resident #406 not attending follow up appts with surgeon following spinal fusion surgery.

Inspectors wroteThis citation pertains to intake: MI00142051 Based on observations, interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 54 who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure 12 hours of in-service education was completed in 5 reviewed certified nurse assistants (CNA) (CNA H, CNA I, CNA O, CNA P and CNA ZZ) of 5 resulting in the potential for performance concerns and decreased resident safety for all residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen on 7/09/2024 at 7:11 PM the following was observed in the reach in refrigerator: 4 salami sandwiches on white bread on tray with parchment paper on top, not sealed, no label and date Lettuce and tomato slices were on top of the parchment paper, not covered, no label and date 1 blue pitcher with some type of juice in it, no label and date The following was observed in the walk-in refrigerator: [...]

Inspectors wroteThis citation has two DPS statements DPS 1 Based on observation, interview, and record review, the facility failed to follow infection prevention standards of practice for 1.) wound dressing change labeling and dating for 1 resident (R7), 2.) disinfecting resident-shared equipment, 3.) appropriate use of indwelling catheter cover for one resident R27, 4.) appropriated use of personal protective equipment (PPE) for EBP (enhanced barrier precautions residents for 2 residents (R7 and R23) of 18 residents reviewed for infection control, resulting in the potential of cross-contamination of blood-borne pathogens, and disease transmission to a vulnerable population.

Inspectors wroteBased on interview and record review the facility failed to maintain an effective training program, which included trainings in resident rights, abuse, neglect, and exploitation, quality assurance, infection control, compliance and ethics, and communication for all new, existing, and contractual nursing department employees resulting in the potential for decreased resident safety for all residents who resided in the facility.

Inspectors wroteBased on interview and record review the facility failed to develop person centered care plans in 3 (Resident #34, Resident #49, and Resident #6) of 18 residents reviewed for person centered care plans resulting in staff not monitoring for side effects of an anticoagulant medication and not monitoring a known skin condition.

Inspectors wroteDuring an interview on 7/9/24 at 7:45 PM, Dietary Aide (DA) F stated, I worked in Activities for a while. The facility fired all the activities aides and kept the Activity Director. The facility had to do budget cutbacks and Activities got hit the hardest. The residents do not always have activities going on. It's sad because the residents like their activities. This citation pertains to intake: MI00142051 Based on observation, interview and record review, the facility failed to provide consistent, meaningful and person-centered activities for 6 of 18 residents (Resident #11, #12, #17, #40, #406, and #34) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of well-being, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort.

Inspectors wroteThis citation pertains to intake MI00143238 and intake MI00142051 Based on observation, interview, and record review the facility failed to ensure sufficient staffing to meet the needs of 5 (Resident #2, Resident #15, Resident #17, Resident #304, and Resident #406) of 18 residents and 12 resident council meeting members reviewed for staffing, resulting in the potential for residents to not maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly monitor and follow resident refrigerator protocol for 19 residents of 19 residents reviewed to ensure temperatures were within range, resulting in the potential for food born illness.

Inspectors wroteThis citation pertains to intake MI00143238 Based on observation, interview, and record review the facility failed to maintain resident dignity in 1 (Resident #15) of 9 residents review for dignity resulting in feelings of frustration and anger.

Inspectors wroteBased on interview and record review the facility failed to provide an environment free from psychosocial abuse in 2 (Resident #2 and Resident #36) of 2 residents reviewed for abuse resulting in feelings of frustration, mental anguish, and a loss of autonomy (freedom from external control or influence).

Inspectors wroteThis citation pertains to intake #MI00145579. Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 1 of 3 residents (Resident #36) reviewed for abuse, resulting in loss of resident's diabetes medication, a delay in treatment of diabetes, and the potential for the resident to not reach their highest practical well-being.

Inspectors wroteBased on interview and record review the facility failed to revise person centered care plans in 1 (Resident #2) of 18 reviewed for care plan revision resulting in the potential for implementation of inaccurate care interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 7 residents (Resident #27 and Resident #406) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient urine incontinence care in 1 resident (Resident #304) of 1 resident reviewed for incontinence care resulting in the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a BiPAP after resident use for infection control for 1 (Resident #13) of 1 resident, resulting in the potential for cross-contamination of respiratory equipment, transmission of disease, and growth of infectious microorganisms.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify post traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 (Resident #65) of 24 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma.

Inspectors wroteBased on interview and record review the facility failed to ensure the nursing staff was evaluated for appropriate competencies and skill sets resulting in the potential for residents of the facility to be unable to maintain the highest practicable physical, mental, and psychosocial well-being and the potential for decreased resident safety for all residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to facilitate appropriate mental health treatment and services for 1 (Resident #406) of 1 resident reviewed for mental health services, resulting Resident #406 being sent to a psychiatric hospital for hospitalization causing psychosocial distress and fear.

Inspectors wroteBased on interview and record review, the facility failed to ensure that follow up with pharmacy recommendations occurred for 1 resident (Resident #22) of 5 residents reviewed for medications resulting in the potential for medication side effects and/or unnecessary medications for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label, date, and store medications in 1 out of 2 medications rooms and 2 of 2 medication carts, resulting in the potential for decreased efficacy of medications and the potential for the compromise of medications and/or the misappropriation of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were eligible for recommended vaccines were offered vaccinations in a timely manner for 2 residents (Resident #6 & #27) out of 5 residents reviewed for immunizations resulting in the potential for developing vaccine preventable disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure they consistently educated, offered and administered COVID-19 vaccines or maintain valid declination in the medical record for 1 resident (Resident #27) of 5 residents reviewed for vaccinations, and failed to educate, offer and track COVID-19 vaccine status staff for facility staff, resulting in the lack of vaccine tracking, the residents right to choose and receive vaccine treatment options, and the right to an informed consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure residents had an operable call light within reach in 1 of 18 residents (Resident #5) reviewed for call lights, resulting in the potential for delayed emergency response and negative resident outcomes.

Inspectors wroteThis citation pertains to intake #MI00142938. Based on observation, interview and record review, the facility failed to provide care to prevent the development, consistent with professional standards of practice in 1 of 3 residents (Resident #405) reviewed for pressure injuries, resulting in the development of pressure ulcers on bilateral heels, and the potential for infection and overall deterioration in health status for all residents at risk for deterioration in skin integrity.

Inspectors wroteThis citation pertains to intake number MI00137705, MI00138640, and MI00140035. Based on interview and record review, the facility failed to ensure adequate staff to meet resident needs for 2 residents (Resident #1 and #3) of 5 residents reviewed for staffing, resulting in unmet resident needs and the potential for all residents to be affected. For additional information see citations F550 and F677.

Inspectors wroteThis citation pertains to intake MI00137705. Based on interview and record review, the facility failed to promote dignity in 2 residents (Resident #1 and #3) of 4 residents reviewed for dignity and respect, resulting in feelings of diminished self-worth 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 ensure staff followed the standard of care for documentation and 1) accurately document physician's orders, 2) document vital signs in the medical record, and 3) document medication at the time given for 1 resident (Resident #9) of 9 residents reviewed for accuracy of physician's orders and accuracy of the medical record, resulting in the potential for residents to receive inappropriate care, lack of communication among care providers, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to MI00140335. Based on interview and record review, the facility failed to provide a means of communication for a resident who's first language was not English in 1 of 3 residents (Resident #7) reviewed for effective communication, resulting in frustration and the inability to communicate resident needs.

Inspectors wroteThis citation pertains to intake MI00142222. Based on interview and record review, the facility failed to provide routine showers to dependent residents for 2 of 5 residents (Resident #3 and #9) reviewed for activities of daily living, resulting in residents feeling dirty and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake MI00138561 and MI00139920. Based on interview and record review, the facility failed to ensure the safety and prevent elopement of 2 of 6 residents (Resident #4 and #6) reviewed for accidents and hazards, resulting in the elopement of Resident #4 and Resident #6 and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility to failed to ensure call lights were in reach for 4 (Resident #53, Resident #357, Resident #358, Resident #359) of 17 residents reviewed for call light placement, resulting in the potential for resident needs not being met.

Inspectors wroteThis citation pertains to intake number MI00128627 and MI00135835. Based on observation, interview, and record review, the facility failed to provide palatable food products for 4 residents (Resident #40, #19, #21, and #49) of 4 residents reviewed for palatability, resulting in dissatisfaction with meals, decreased food acceptance, the potential for nutritional decline, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteR38 According to the Minimum Data Set (MDS) 3/23/2023, R38 scored 5/15 (cognitively impaired) on his BIMS (Brief Interview Mental Status), required extensive assistance of one-person physical assistance to move/change position in bed, with diagnoses that included dementia, manic depression, and Parkinson's disease. Observed on 6/05/23 at 10:48 AM, R38 had a transmission-based precautions isolation cart outside of his room containing PPE (personal protection equipment). There was no transmission-based precautions signage on the resident's door indicating the type of precaution or what PPE was required to enter the room. Review of R38's Change in Condition 6/3/2023 (Saturday), reported the resident had signs/symptoms of a respiratory infection that was identified with a dry and nagging cough with almost lost of voice. R38 was reported to have been placed in isolation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medications for 1 (Resident #53) of 1 residents reviewed for self administration of medication, resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident choices were provided during preparation of medication for 1 (Resident #53) of 1 residents, from a total sample of 17 reviewed for resident choices resulting in dissatisfaction in care.

Inspectors wroteBased on interview and record review, the facility failed to provide prompt resolution of grievances for 1 resident (Resident #46) of 17 residents, reviewed for resolution of grievances, resulting in delayed resolution of resident's complaint/grievance and resident frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) apply barrier cream during incontinence care for 1 resident (Resident #11) of 1 resident reviewed for incontinence care and 2) provide a physician's order for oxygen therapy for 1 resident (Resident #2) of 3 residents reviewed for respiratory care, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers and hygiene care were provided per resident preference and plan of care for 2 (Resident #358 and Resident #41) of 5 resident reviewed for Activities of Daily Living (ADL) care, resulting in inadequate personal hygiene, missed showers, and dissatisfaction with care and hygiene concerns. Findings Include: Resident #41 Review of an admission Record revealed Resident #41, was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 4/13/ 23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #41 was moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) ensure residents received recommended services following occupational therapy discharged , and 2.) thoroughly assess and provide consistent treatment of a skin condition, for 2 (Resident #21 and #53) of 17 residents, reviewed for quality of care, resulting in Resident #21 not meeting his highest practicable physical and psychosocial well-being due to being unable to propel wheelchair, and inadequate treatment of dry itchy skin for Resident #53.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement fall prevention interventions for 2 (Resident #358 and #32) of 2 residents reviewed for falls, resulting in inadequate fall prevention interventions and potential for further falls and major injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a oxygen delivery equipment for infection control for 1 of 3 residents (R2) reviewed for respiratory care, resulting in the potential for infections and unmet medical needs.