Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteThis citation pertains to intake # 1234673Based on interviews and record review, the facility failed to develop and implement a person-centered plan of care for one Resident (#44) of 12 residents reviewed for comprehensive care plans, resulting in the potential for aspiration and impaired physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to employ a certified dietary manager or certified food service manager to manage the food service department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills to carry out functions of the food and nutrition services. This deficient practice had the potential to affect all 38 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional stands for food service safety as evidenced by:- Failing to ensure labeling of food- Failing to ensure expired food was discarded- Failing to prevent possible contamination of fresh produce- Failing to prevent possible cross contamination from kitchen appliances- Failing to ensure the ice machine drainage pipe has a two-inch air gap to the floor drainThis deficient practice had the potential to result in food borne illness among any or all 38 residents in the facility who receive meals.

Inspectors wroteBased on observation, interview, and record review the governing body failed to hire a licensed Nursing Home Administrator (NHA) to oversee the day-to-day operations of the facility and ensure the federal regulations are being followed.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective, and comprehensive Quality Assurance Performance Improvement (QAPI) program that addresses the full range of services the facility provides. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to establish priorities for its improvement activities, develop and implement action plans, and review or analyze data collected under the Quality Assurance Performance Improvement (QAPI) program. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize their policy for antibiotic stewardship program and failed to ensure accurate monitoring of antibiotic use resulting in the potential for inappropriate antibiotic utilization and worsening or non-improving infections for all 38 residents residing within the facility as well as the potential for antibiotic resistance. Review of the facility's Infection Prevention and Control binder revealed multiple residents who had taken antibiotics on different occasions over different months of the look back period for antibiotic tracking sheets had an N under the antibiotic tracking sheet area of was criteria followed. The criteria per facility protocol had McGeer's Criteria listed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the acting Infection Control Preventionist (ICP) had the proper training and certification to ensure infection control measures were in place and being followed per federal regulation and the facility's policy, resulting in the potential for all residents residing in the facility to be at risk for serious infections and complications from different types of infections.

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plan interventions for 1 Resident (#7) of 12 residents reviewed for care plan revision, resulting in the potential for unmet resident care needs, increased falls, unsafe resident environment, and resident injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care i.e. bathing and grooming services for one Resident (R5) of two residents reviewed for ADL care which resulted in unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services including humidification and routinely changing oxygen tubing for one Resident (#11) of two residents reviewed for oxygen services. This deficient practice resulted in discomfort and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5% in two Residents (#2 & #7) of three residents reviewed for medication administration, resulting in 2 medication errors in 26 opportunities for error and a 7.69% medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for two Residents (Resident #8 and Resident #31) of three residents reviewed for arbitration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light communication system was fully operational for 6 Residents (#1, #2, #6, #9, #10, & #11), out of the total population of 46 residents residing in the facility. This deficient practice resulted in residents' inability to utilize the call light system for emergency care needs, delayed provision of care and resident dissatisfaction.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding facility rules and regulations, including denture loss, prior to or upon admission to the facility for one Resident (R2) of three residents reviewed for notice of rights and rules.

Inspectors wroteBased on interview and record review, the facility failed to respond timely to a change in condition for one Resident (R2) of three Residents reviewed for a change in condition. This deficient practice resulted in delayed transfer and treatment of an identified changed in condition.

Inspectors wroteBased on interview and record review, the facility failed to appropriately assess weights to assist in identification and prevention of significant weight loss for three Residents (R2 , R4, & R8), of six residents reviewed for weight management. This deficient practice resulted in inadequate weight documentation/tracking and the development of a significant weight loss for R2.

Inspectors wroteThis citation has two deficient practice statements: Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program, as evidenced by the failure to complete the following during a COVID-19 outbreak: 1. Implement measures to contain the outbreak. 2. Complete infection surveillance, tracking, trending, and monthly summaries, 3. Implement effective Transmission Based Precautions (TBP) and ensure appropriate donning and doffing of personal protective equipment (PPE). This deficient practice resulted in immediate jeopardy when 40 Residents out of a total facility census of 45 residents contacted COVID-19, including one death (R102), 4 Resident (R102, R14, R11 and R45) hospitalizations, and sustained outbreak transmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment for all facility residents. This deficient practice resulted in the potential for injury and dissatisfaction with the living environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nurse Aides (CNA) [ L & N] had yearly competency training, including demonstration in skills and techniques necessary to care for the facility population.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for five of five Certified Nurse Aides (CNA's) [F, L, M, N, & O] at least once every 12 months.

Inspectors wroteBased on interview and record review, the facility failed to enter the census (total number of residents) on the facility staffing information posting used to calculate appropriate levels of staffing. This deficient practice resulted in the potential for inaccurate staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: - Failing to ensure expired food was discarded. - Failing to maintain three freezers in a sanitary condition. - Failing to ensure the dietary ice machine was cleaned in a manner which prevented potential contamination of ice used by residents. - Failing to ensure the facility dishwasher properly sanitized all items. This deficient practice had the potential to result in food borne illness among any or all 46 residents in the facility who receive meals.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive facility assessment that included training that resulted in the potential for unidentified resources necessary to provide care and services to the resident population.

Inspectors wroteBased on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 45 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement, monitor, and document the antibiotic stewardship program. This deficient practice has the potential to affect all residents with exposure to unnecessary medications, antibiotic resistance, and infection.

Inspectors wroteBased on interview and record review, the facility failed to educate and offer COVID-19 vaccination for staff resulting in increased risk for COVID-19 infections and the potential spread of COVID-19 infection to other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of potential entrapment for all facility residents. This deficient practice resulted in the potential for risk of injury to all 47 vulnerable facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of potential entrapment for all facility residents. This deficient practice resulted in the potential for zones of entrapment to remain unidentified posing a risk to all 45 vulnerable facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility: - failed to ensure that one resident (R2) received food in the appropriate form as prescribed by a physician and - failed to ensure the appropriate nutritive content was served to 46 residents receiving meals from the dietary department.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer notification to the resident and resident's representative for one Resident (R45) of two residents reviewed for transfers out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care per comprehensive care plan, per physician orders and without proper infection control practices for one Resident (R47) out of 12 sample residents. This deficient practice resulted in the potential for delayed wound healing and potential for infection.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent a fall for one Resident (R50) of two residents reviewed for falls. This deficient practice resulted in a fall with injury (fractured hip), and a decline in condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of training on resident rights training for two of five staff reviewed for resident right training. This deficient practice had the potential of facility staff violating the rights of all 45 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of training on Quality Assurance Performance Improvement (QAPI) training for one L of five staff reviewed for QAPI training. This deficient practice had the potential to result in unmet care needs due to an ineffective performance improvement program.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of training on infection control for one of five staff reviewed for infection control training. This deficient practice had the potential for the spread of diseases and infectious processes to all 45 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aide training of no less than 12 hours per year for two Certified Nursing Assistants (CNA) L and N of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 45 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide and document a safe and orderly involuntary discharge for one Resident (R1) of three residents reviewed for facility discharge. This deficient practice resulted in harm, based on a reasonable person standard, when R1 was discharged to home without notice to family members living in the home, no provision of home health services upon discharge from the facility, emotional distress due to lack of care, and return to the hospital resulting from unaddressed care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a 30-day written notice of discharge with notification to the Office of the State Long-Term Care Ombudsman and the State Agency for one Resident (R1) of three residents reviewed for notice before discharge. This deficient practice resulted in an inappropriate discharge from the facility without notification of discharge and appeal rights to the Resident and/or Resident's Representatives.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services pertaining to discharge for one Resident (R1) of three residents reviewed for discharges. This deficient practice resulted in an inappropriate involuntary discharge, failure to inform the Resident and/or Resident Representative of their involuntary discharge appeal rights, and emotional distress based on a reasonable person standard.

Inspectors wroteLinked intake MI00142531 Based on interview and record review, the facility failed to report timely an allegation of misappropriation of resident property (narcotics) to the State Agency (SA) for one Resident (R4) of four residents reviewed for abuse reporting.

Inspectors wroteLinked intake MI00142531 Based on interview and record review, the facility failed to conduct a thorough investigation for a misappropriation of resident property (narcotic medication) for one Resident (R4) of four residents reviewed for abuse. This deficient practice resulted in undetected abuse and/or misappropriation and the potential for unmet care needs:

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failing to hold food at proper temperature being stored in a walk in cooler. These deficient practices have the potential to result in food borne illness among any and all 53 residents of the facility.

Inspectors wroteThis citation pertains to intake # MI00131776 This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak. This deficient practice placed all residents residing in the facility at risk for the potential of the development and spread of disease and infection and the potential for an outbreak to go undetected.

Inspectors wroteBased on observations and interview, the facility failed to provide an environment which was safe, sanitary and functional for residents, staff and visitors, as evidenced by compressed gas cylinders being unrestrained, corridor hand rails which were missing or in conditions to cause injury, and allowing a potential cross connection between the potable water supply and garbage disposal drain in the kitchen. These deficient practices have the potential to result in injury or illness to all 63 residents in the facility.

Inspectors wroteResident #28 (R28) Review of an admission Record reflected R28 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, weakness, urine retention, dementia without psychotic disturbance, mood disturbance or anxiety and abnormalities of gait and mobility. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and was independent with locomotion on the unit. Resident #25 (R25) Review of an admission Record reflected R25 admitted to the facility with diagnoses that included anxiety, a personal history of traumatic brain injury, adjustment disorder, contracture of the right hand, post-traumatic seizures and abnormalities of gait and mobility. [...]

Inspectors wroteResident #1 (R1) Review of an admission Record reflected R1 admitted to the facility with diagnoses that included Type 2 Diabetes with foot ulcer, morbid (severe) obesity, bipolar disorder, dysphagia, obstructive sleep apnea, muscle weakness, borderline personality disorder, major depressive disorder, generalized anxiety disorder and gastroparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R1 needed extensive assistance from two people for bed mobility, transfers and toilet use and needed extensive assistance from one person for dressing. [...]

Inspectors wroteThis citation pertains to intake MI00131776 Based on interview and record review, the facility failed to honor resident preferences for customary routines and activities for 3 residents (Residents #1, #30 and #48) resulting in depersonalization and diminished quality of life. Resident #1 (R1) Review of an admission Record reflected R1 admitted to the facility with diagnoses that included Type 2 Diabetes with foot ulcer, morbid (severe) obesity, bipolar disorder, dysphagia, obstructive sleep apnea, muscle weakness, borderline personality disorder, major depressive disorder, generalized anxiety disorder and gastroparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care to two resident's (Resident #31 and Resident #36) by (a) not administering pain medications, (b) not documenting neurological assessments completely, (c) not tracking behaviors, (d) not re-assessing the need for high doses of antipsychotic medications, (e) not checking vital signs on a daily basis as required by documentation, (f) not monitoring lab values when administering supplements, and (g) not notifying the physician when a medication was unavailable for greater than 2 days, resulting in the resident's not functioning at the highest possible functional level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring, assessment and care for 1 resident (Resident #3) with an indwelling catheter, reviewed for urinary catheter/UTI (urinary tract infection) care, resulting in the increased potential for infection and urinary complications.