Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment, and ensure proper cooling of food affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. On 05/22/25 between 9:10 AM and 10:05 AM during the initial tour with Certified Dietary Manager (CDM) A the following concerns were observed: Observation of the cookline revealed the Accutemp Steamer had one end of a drain line directly connected to the bottom of the steamer. The other end of the drain line went down through the grated floor drain and was submerged directly into the sewer drainpipe. Review of the FDA 2017 Food Code Section, 5-402.11 Backflow Prevention. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control policies and procedures for glucometer cleaning, equipment cleaning and Management of C. Difficile Infection for two residents (R16 & R39) out of a total sample of 18 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 residents (Residents #11, #50, #7, and #28) out of 18 residents and residents receiving controlled medications on the Garden Unit, reviewed for the provision of nursing services.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist in finding an appropriate fitting wheelchair for one (R44) of one resident reviewed for wheelchair needs.

Inspectors wroteBased on interview and record review, the facility failed to notify the provider of abnormal vital signs for 1 of 6 residents (Resident #11) reviewed for notification of change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and address edema, significant weight gain, and follow through with physician orders for one (R44) who was reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement preventative care and services of pressure injuries for one (R15) of two residents reviewed for pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement measures to prevent foot drop for one (R15) of one resident reviewed for positioning.

Inspectors wroteThis citation pertains to MI00147646 Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview and record review the facility failed to protect the resident's right to be free of Abuse from physical restraints for one resident (R101) of six residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment that was free from potential accidents and hazards for 7 of 7 residents (Resident #23, Resident #37, Resident #4, Resident#42, Resident #6, Resident #46, and Resident #58 ) reviewed for accidents and hazards.

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness and repair. This resulted in the potential for contamination of linens and domestic water. Findings Include: During a tour of the facility, with Maintenance Director (MD) G, starting at 12:23 PM on 7/15/24, the following environmental concerns were noted: Observation of the Beauty shop hair wash sink was found to not have proper backflow prevention on the hose for the hair sprayer. The hose was able to drop below the overflow rim of the sink and be a submerged inlet with no inline atmospheric vacuum breaker. Observation of the 200 Hall linen closet found an open wire rack shelving with no bottom barrier on the bottom rack to protect against contamination from cleaning or accumulation of debris on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and clean homelike environment for two facility Residents (R42 and R23). R42 Review of the Electronic Medical Record (EMR) admission Record reflected R42 originally admitted to the facility 3/6/23 with pertinent diagnoses that include Repeated Falls, Unsteadiness on Feet, and Morbid Obesity. Review of the MDS dated [DATE] reflected R42 requires partial/moderate assistance with transfers but is non-ambulatory and is confined to a motorized wheelchair for mobility. The medical record reflected R42 is cognitively intact and is her own responsible party. On 7/15/24 at 10:42 AM in the room of R42 it was observed that all flat surfaces to include over the bed table, dresser/ nightstand and counter tops were full and stacked in an unorganized manner with the resident's belongings. [...]

Inspectors wroteThis citation pertains to Intake # MI00145106 Based on observation, interview, and record review, the facility failed to facilitate administration of, and monitor, a bowel preparation protocol for one Resident (R30) and get him to an appointment for a scheduled colonoscopy, resulting in the resident becoming distraught due to lack of staff assistance to meet his medical needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement care to prevent skin break down and maintain range of motion related to a severe contracture for 1 Resident (R6), resulting in R6 having intermittent skin irritation and the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a thorough assessment of PTSD (post-traumatic stress disorder) and develop and implement an individualized care plan for 1 resident (Resident #60).

Inspectors wroteBased on interview and record review, the facility failed to provide collaborative hospice care for I Resident (R6) of 2 Residents reviewed for hospice care, resulting in the potential for unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention measures for 1 Resident (Resident #6) of 2 Residents reviewed for Foley Catheter, resulting in the potential for infection.

Inspectors wroteBased on interview and record review, the facility failed to monitor a diabetic resident's blood sugars with insulin administration for 1 resident (Resident #105) of 3 residents reviewed for diabetic care, resulting in the potential for unnoticed hyperglycemia and hypoglycemia and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis Citation pertains to Intake Number MI00142207. Based on interview and record review, the facility failed to protect Resident #103's (R103) right to be free from neglect, which resulted in R103's physical deterioration and subsequent death. Immediate Jeopardy: The Immediate Jeopardy began on 12/12/23 when Resident #103 (R103) was admitted to the facility from the hospital for short-term rehab following a left arm fracture and a Urinary Tract Infection (UTI). An admission nursing assessment identified only a pressure injury on the right heel. The facility failed to follow hospital discharge instructions, physician's orders, and did not obtain follow-up consults for wound care which resulted in the worsening of and development of wounds on the right 5th toe, right heel, right lateral foot, right lateral lower leg, sacrum, coccyx and thoracic spine. [...]

Inspectors wroteThis Citation is related to Intake Number MI00141306 Based on observation, interview, and record review, the facility failed to provide quality care to 3 of 5 residents (Resident #17, Resident #101, and Resident #126) reviewed for quality of care, resulting in untreated sepsis and septic shock for R17.

Inspectors wroteThis citation pertains to Intake Numbers: MI00-141372, MI00-141306, MI00-142123, MI00142-230, and MI00142-016 This citation has two DPS statements. Statement #1 Based on interview and record review, the facility failed to provide adequate supervision based on current medical concerns for 2 of 2 residents (Resident #107 and Resident #104) reviewed for falls, and failed to communicate the falls to therapy staff for 1 of 1 residents (Resident #107), resulting in fractures for both Resident #107 and Resident #104.

Inspectors wroteThis citation is related to intakes #'s: MI00-141306, MI00-141353, MI00-141884, MI00-142008, MI00-141471, and MI00-142016. Based on observation, interview, and record review, the facility failed to ensure (a) call lights were answered and resident needs were met in a timely manner, (b) that call lights were within reach and accessible, and (c) that fluids were available or within reach for 6 of 6 residents ( Resident #127, Resident #100, Resident #101, Resident #104, Resident #119, and Resident #116), reviewed for accommodation of needs, resulting in delays for staff to meet the residents needs and residents unable to hydrate with or without staff assistance.

Inspectors wroteThis citation pertains to intake #s: MI00-141471 and MI00-142016 Based on interview and record review the facility failed to follow professional standards of nursing practice for medication administration for 4 residents (Resident #111, #112, #113, and #114), out of 6 residents reviewed for the provision of nursing services, resulting in medication not administered following the physician order and medications administered outside of the physician ordered parameters.

Inspectors wroteThis citation pertains to intakes: MI00-141465 and MI00-141884 Based on observation, interview and record review, the facility failed to 1.) provide care following the comprehensive care planned interventions and facility policy to prevent the development and worsening of avoidable pressure injuries and 2.) assess, monitor, and provide ordered treatment for residents with new/worsening pressure injuries/wounds for 2 residents (Resident #116 and #117) out of 6 residents reviewed for pressure injuries/wounds resulting in increased pain, skin impairment, and the worsening of a wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and assess 1 of 2 residents (Resident #101) reviewed for positioning.

Inspectors wroteThis citation pertains to intake #s: MI00-141465 and MI00-142016 Based on interview and record review, the facility failed to maintain clear and concise controlled substance counts and failed to accurately document administration of controlled substances for 4 residents (Resident #101, #122, #123, and #124). Resident #101 (R101) Review of an admission Record revealed R101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: epilepsy and neuralgia (nerve pain.) Review of R101's Physician Order with a start date 12/5/23 revealed, PHENobarbital Oral Tablet 64.8 MG (Phenobarbital) Give 1 tablet via NG-Tube at bedtime for Seizure. Review of R101's Controlled Substance Log (narcotic count sheet) revealed Phenobarbital was not administered at bedtime on 1/16/24 or 1/23/24. [...]

Inspectors wroteThis citation is related to intake # MI00-141456 and MI00-141884 Based on observation, interview, and record review, the facility failed to follow established procedures regarding the storage of medication and controlled substances in 3 of 5 medication carts, 1 of 2 medication store rooms and, 1 of 1 refrigerators used to store controlled substances, reviewed for the labeling and storage of drugs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate infection prevention and control practices in 1 of 2 shower rooms reviewed, and 4 residents observed for skin and wounds (Resident #100, #113, #202 and #201) out of 8 residents reviewed for quality care, resulting in cross contamination and the potential for the spread of pathogens throughout the facility affecting all residents.

Inspectors wroteThis citation pertains to intakes: MI00-141471 and MI00-141884 Based on interview and record review, the facility failed to address and resolve grievances for 1 of 4 residents (Resident #108) reviewed for grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for 1 resident (Resident #108) out of 4 residents reviewed for respiratory care, resulting in the potential for respiratory illness from cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to implement its Antibiotic Stewardship Program for 1 resident (Resident #100) out of 14 residents reviewed for quality care, resulting in the potential for antibiotic resistance.

Inspectors wroteThis citation pertains to intakes M100140527 and M100141143. Based on observation, interview, and record review, the facility failed to provide care and implement interventions related to pressure ulcers for 2 (Resident #10 and Resident #13) of 4 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation and record review, the facility failed to implement documented care interventions for 1 of 3 residents (Resident #17) reviewed for accidents and hazards, resulting in the potential for choking, and injuries sustained during bed mobility or a fall from the bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate infection prevention and control practices in 1 of 2 shower rooms reviewed, and 4 residents observed for skin and wounds (Resident #100, #113, #202 and #201) out of 8 residents reviewed for quality care, resulting in cross contamination and the potential for the spread of pathogens throughout the facility affecting all residents.

Inspectors wroteThis citation pertains to intake M100140108, M100140527 and M100141143. Based on observation, interview and record review, the facility failed to respond to call lights timely for 3 (Resident #13, Resident #19, and Resident #20) of 4 residents reviewed for call light responses and accommodation of needs.

Inspectors wroteThis citation pertains to intakes MI00140221 and MI00140108. Based on observation, interview and record review, the facility failed to provide showers for 2 (Resident #2 and Resident #12) of 5 residents reviewed for showers.

Inspectors wroteThis citation is linked to intake #MI00140108 Based on observation, interview, and record review, the facility failed to follow facility policies/procedures and best practice standards for 1 of 2 residents (Resident #17) reviewed for tube feed services, resulting in the potential for (a) the incorrect amount of nutrition and hydration delivered to the resident, (b) contaminated equipment inserted into the G-tube, and (c) growth of bacteria on disposable and time limited supplies.

Inspectors wroteThis citation is linked to intake #MI00139451 Based on interview and record review, the facility failed to follow procedures for administering and documenting the use of controlled substances for one of two residents (Resident #1) reviewed, resulting in the potential for medication diversion and the resident not receiving physician ordered pain medications as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain locked treatments carts, for 3 of 4 treatment carts, out of 4 carts observed, resulting in the potential for accidental ingestion and misappropriation of physician ordered treatments.

Inspectors wroteThis citation pertains to intake M100141143. Based on interview and record review, the facility failed to address and resolve grievances for 1 (Resident #13) of 1 resident reviewed for grievances.

Inspectors wroteThis citation refers to MI00140350 Based on interview and record review, the facility failed to protect the resident's right to be free from physical restraints for 1 of 20 residents (R9), resulting in R9 being unable to move or use her call light for assistance for approximately 10 hours.

Inspectors wroteThis citation pertains to intake M100140527. Based on observation, interview and record review, the facility failed to provide toileting/incontinence care for 1 (Resident #12) of 2 residents reviewed for toileting/incontinence care. Review of concerns reported to the State Agency were allegations of staff not answering the call light and the resident had to wet the bed then forced to take herself to the bathroom using a walker. Resident #12 (R12) Review of a Face Sheet revealed R12 originally admitted to the facility with pertinent diagnoses of Hemiplegia and hemiparesis (one sided weakness), diabetes, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed severely cognitively ---- And has limited range of motion on one side of upper and lower extremities and is always incontinent. MDS is not completed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for 1 resident (Resident #108) out of 4 residents reviewed for respiratory care, resulting in the potential for respiratory illness from cross contamination.

Inspectors wroteBased on interview and record review the facility failed to implement its Antibiotic Stewardship Program for 1 resident (Resident #100) out of 14 residents reviewed for quality care, resulting in the potential for antibiotic resistance.

Inspectors wroteThis citation pertains to intake # MI00139197, MI000136833, MI000137737. This citation has multiple Deficient Practice Statements (DPS), A & B. DPS A Based on interview and record review, the facility failed to acknowledge, identify, and provide adequate supervision to prevent an elopement and ensure the safety of 1 resident (Resident #66), reviewed for risk of elopement, placing all residents with a history of wandering and/or elopement behavior at risk of serious harm and/or death. This deficient practice resulted in an Immediate Jeopardy beginning on 8/29/23 at 2:40 PM, when R66, a known elopement risk, eloped from the facility after Receptionist F allowed him to leave the building unattended. Receptionist F did not immediately recognize R66 as a resident and R66 was not included in the elopement risk binder. [...]

Inspectors wroteThis citation pertains to intake # MI00136667 and MI000137509 Based on interview and record review, the facility failed to maintain clear and concise controlled substance count and failed to accurately document administration of controlled substances for 4 residents (Resident #53, #70, #71, and #60), resulting in the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances. Resident #53 (R53) Review of an admission Record revealed R53 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain syndrome. Review of R53's Medication Administration Record revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 6 hours as needed for pain. Start Date 4/24/23. [...]

Inspectors wroteThis citation pertains to intake MI000138229 Based on interview and record review, the facility failed to ensure residents were free from neglect for one resident (Resident #65) who was left unattended in a shower room for 45 minutes after staff forgot she was there, resulting in fear and ongoing anxiety.

Inspectors wroteThis citation pertains to intake # MI00136833 Based on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving enteral tube feedings per facility policy and professional standards of care for 1 resident (Resident #2-41) reviewed for enteral tube feedings, resulting in the potential for aspiration pneumonia and an overall deterioration of health status.

Inspectors wroteThis citation pertains to intake #: MI00129228 and MI00130172 Based on observation, interview, and record review the facility failed to; 1. Keep general cleanliness in the walk in cooler and dish area fans; 2. Properly store raw animal product; 3. Clean food and non-food contact surfaces to sight and touch; and 4. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 84 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, starting at 8:52 AM on 4/30/23, it was observed that an accumulation of debris was evident around the perimeter of the floor and around wheels of the storage racks. Further review found staining and spillage at the back left corner of the unit. [...]

Inspectors wroteThis citation pertains to intake #MI00129228, MI0013017, MI00132506, MI00134457, MI00135649 and MI00135650. Based on observation, interview, and record review, the facility failed to maintain dignity and respect for 5 residents and members of the confidential resident council group, Resident #3 (R3), R33, R34, R47 and R75, reviewed for respect. This deficient practice resulted in feelings of disrespect and the potential for avoidable negative psychosocial outcomes for residents.

Inspectors wroteBased on interview and record review, the facility failed to complete and provide 4 residents and their advocates baseline care plans within 48 hours of admission (R3, R137, R139, R238), resulting in the potential for unmet needs to be addressed in their plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide consistent, meaningful, and person-centered activities for 5 residents (Resident #1, #288, #60, #289, and #47) and residents in a confidential group meeting, resulting in the potential for loss of interaction, self-esteem, growth, sense of wellbeing, connectedness, creativity, pleasure, and comfort.

Inspectors wroteDuring an observation on 08/30/23 at 12:40 PM, the Brookside-even medication cart contained a residents Insulin Glargine pen that had been opened and used, but was not labeled with an open date or an expiration date. During an observation on 08/30/23 at 12:55 PM, the Brookside-odd medication cart contained 1 and 1/2 loose unidentified pills in the second drawer. During an observation on 08/30/23 at 1:07 PM, the Lakeshore Med Storage Room: (a) contained an unlocked refrigerator that stored controlled substances, thereby storing controlled substances behind a single locked door and not double locked, (b) did not have a refrigerator temperature check set up. During an interview, at the time of the observation, the Assistant Director of Nursing (ADON) indicated that the refrigerator should have a temperature log set up so that it can be checked routinely by staff. [...]

Inspectors wroteThis citation pertains to intake #: MI00129228, MI00130172, MI00132801, MI00134457 and MI135739. Based on observation, interview, and record review, the facility failed to provide 1.) meals in a timely manner, 2.) palatable food, and 3.) evening snacks to 1 resident (Resident #34) and residents in the confidential group meeting, resulting in the potential for decreased food consumption and nutritional decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer different accommodations (offer a different room) to the 4 Residents in rooms [ROOM NUMBERS] while their hand sink ceased to function over the last several weeks, potentially affecting their needs for quality and continuity of care by staff and resulting in longer waits for care to be completed.

Inspectors wroteBased on interview and record review, the facility failed to appropriately formulate advance directives for 2 residents, Resident #33 (R33) and Resident #49 (R49) reviewed for advance directives. This deficient practice resulted in R33's advance directive signed by the non activated legal decision maker and R49's code status was unclear regarding treatments desired.

Inspectors wroteThis citation pertains to intake number MI00136215, and MI00135650. Based on interview and record review, the facility failed to implement the abuse policy to report abuse timely and thoroughly investigate for one resident, Resident #75 (R75), reviewed for abuse. This deficient practice resulted in R75 feeling unsafe and the potential for other residents to be at risk for ongoing abuse.

Inspectors wroteThis citation pertains to intake number MI00135650. Based on interview and record review, the facility failed to implement interventions from a comprehensive care plan for 2 residents (Resident #41 and Resident #75), resulting in the potential for impaired physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake number MI00135650. Based on observations, interview and record review, the facility failed to prevent accident hazards for 1 Resident (R75) and failed to have safety measures in place for 2 Residents (R68 and R139), resulting in R75 hitting her head during care, R68 not having proper head support during a lift transfer and the potential for injury when R139's cigarette's were not secured and she was signing out of the facility independently.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 Resident (R10) did not have unintended weight loss, resulting in R10 having unplanned weight loss and the potential to delay healing of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving enteral tube feedings per facility policy and professional standards of care for 1 resident (Resident #41) reviewed for enteral tube feedings resulting in the potential for aspiration pneumonia and an overall deterioration of health status.

Inspectors wroteBased on observations, interviews and record review, the facility failed to clean and label residents' respiratory equipment for 1 Resident (R31) in a manner that prevents contamination and the risk of respiratory illnesses, resulting in the potential for respiratory illnesses.

Inspectors wroteBased on observations, interviews and record review, the facility failed to adequately assess and address pain for 2 Residents (R3 and R10), resulting in both Residents experiencing uncontrolled pain for long periods of time.

Inspectors wroteBased on interview and record review, the facility failed to ensure communication, collaboration, and coordination of care with the dialysis unit for one resident, Resident #77 (R77) reviewed for dialysis care. This deficient practice resulted in minimal assessments being conducted before and after dialysis treatments, communication, collaboration, or coordination of care between the facility and the dialysis unit for R77 and the potential for change in care or treatment to be missed or not provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #77) received his cancer medication according to physician order, resulting in a significant medication error when the facility failed to acquire and provide this necessary medication.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide collaborative hospice care for 1 Resident (R3) resulting in the potential for care and service to be missed.