Mission Point Nursing & Physical Rehabilitation Ce

Inspectors wroteThis citation pertains to Incident 3044880Based on interview and record review, the facility failed to ensure a snack was given in a form consistent with physician diet orders for one (R302) of four residents reviewed for therapeutic diets resulting in R302 choking on a peanut butter sandwich requiring emergency intubation and was hospitalized with extensive hypoxic ischemic brain injury [brain damage due to loss of oxygen].

Inspectors wroteThis citation relates to Intake 3020377. Based on interview and record review, the facility failed to transcribe a medication accurately per physician orders for one Resident (R102) of two residents reviewed for medication administration.

Inspectors wroteThis citation pertains to intake 2966880. Based on observation, interview and record review, the facility failed to maintain clean, comfortable, homelike environment for multiple residents that reside in the facility, including those on the A, B and D units.

Inspectors wroteThis citation pertains to intakes 2607613, 2658268, 2666429, 2793060. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by a staff, verbal abuse by a resident, physical abuse by a resident, and failed to protect the resident's right to be free from neglect for five (R1, R30, R53, R64 and R76) of six residents reviewed for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to report witnessed resident to resident verbal abuse and an injury of unknown origin to the State Agency for four (R1, R30, R53, and R80) of six residents reviewed for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of plumbing and the ice machine, resulting in an increased potential for contamination including the water supply affecting all residents. Findings Include:On 3/30/2026 at 9:00 AM during a kitchen tour with dietary manager (DM) 'Z' observed sewer gas odor present near the sub floor grease trap by the 3-compartment sink. Also smelled the same odor at 3 in-floor drains, and near 3 kitchen sink drains. During this observation, when DM 'Z' was asked if he smelled this odor or knew what the issue was, DM 'Z' indicated having a diminished sense of smell and was not aware of the odor or what the issue may be. When asked about the frequency of service for the grease trap, DM 'Z' indicated about every 6 months and that the building was serviced by village of [NAME] sanitary sewer. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin for one (R80) of six residents reviewed for abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to address a resident's ileostomy [surgically created opening to allow waste to exit the body] for one [R35] of one resident reviewed for ostomies.

Inspectors wroteThis citation pertains to intake 2801923. Based on observation, interview, and record review, the facility failed to thoroughly assess and document a change in condition for one (R79) of two residents reviewed for changes in condition.

Inspectors wroteThis citation pertains to Intake 2966880Based on observation interview and record review the facility failed to ensure physician/extender pressure ulcer treatment orders were followed for one [R55] of one resident reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement fall prevention interventions according to the resident's plan of care for one (R52) of two residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nephrostomy tube [surgically implanted catheter into the kidney to drain urine] drainage bags were positioned correctly for dependent drainage for one [R25] of one resident reviewed for nephrostomy tubes.

Inspectors wroteThis citation pertains to intake: 2582047. Based on interviews and record reviews the facility failed to identify a substance use disorder (sud) -alcohol, and failed to implement a care plan/interventions for the sud, for one (R302) of one resident reviewed for elopements, resulting in R302 having left the facility without the knowledge of staff.

Inspectors wroteThis citation pertains to intake: 2583159. Based on interview and record reviews, the facility failed to protect the resident's right to be free from mistreatment by a staff member for one resident (R303) of two residents reviewed for neglect/abuse.

Inspectors wroteThis citation pertains to intake: 2582047. Based on interviews and record reviews the facility failed to complete a thorough investigation for an elopement and failed to submit accurate details to the State Agency (SA) regarding the elopement incident for one (R302) of one resident reviewed for an elopement.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all admission orders were reported and reconciled with the Physician for one (R302) of one resident reviewed for an elopement.

Inspectors wroteThis citation pertains to intake: 2570372. Based on interview and record reviews the facility failed to accurately identify a pressure wound, accurately documented the worsening and correct staging of a coccyx wound for one (R301) of one resident reviewed for pressure wounds.

Inspectors wroteThis citation pertains to intake: 2570372. Based on interview and record reviews the facility staff failed to follow the recommendation of the psych nurse practitioner (NP) and failed to identify a change of condition (urinary tract infection - uti) as the cause of a mental status/behavioral changes for one (R301) of two residents' reviewed for neglect/abuse.

Inspectors wroteThis citation pertains to intake: 2570372. Based on interview and record reviews the facility failed to identify, follow up and follow the facility policy on weight loss for one (R301) of one resident reviewed for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective plan of action to correct identified quality deficiencies related to controlled substances (medications regulated by the government due to having a high risk of abuse and/or addiction), resulting in the continuation of deficient practices related to having an effective process to accurately account for all controlled substances for six (R704, R705, R706, R707, R709, and R710) of seven residents reviewed. This had the potential to affect all residents who resided in the facility who were prescribed controlled substances.

Inspectors wroteThis citation pertains to intake #s MI00150458 and MI00152210. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R704), of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteOn 2/4/25 at 9:32 AM, Room D151-1 was observed to have privacy curtains soiled with dark brown debris. On 2/4/25 at 10:00 AM, Room D148-1 was observed to have an overbed tray table that had peeled away edges which exposed the particle board (porous material) underneath. Observations from 2/4/25 - 2/5/25 also identified concerns in the fishbowl lounge which had a large ceiling vent (approximately 3 feet x 3 feet) which had a thick layer of dusty build-up on the outside grid covering. The bathroom in the hallway just outside of the fishbowl lounge was observed to have a ceiling fan that was covered in thick, stringy, heavy dust build-up on the outside of the vent grid. On 2/5/25 at 1:30 PM, an interview was conducted with the Maintenance & Housekeeping Manager (Staff 'I'). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent dialysis communication documentation and assessments were completed for one (R26) of one resident reviewed for dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate storage of medications and treatments/biologicals in two of three medication rooms, one of one treatment cart, and one of four medication carts, resulting in potential for unauthorized entry, misuse, and contamination. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessments were completed for two (R26 and R58) of 17 residents reviewed for Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments, monitoring and treatments were provided for one (R27) of two residents reviewed for non-pressure wound care.

Inspectors wroteBased on observation and interview, the facility failed ensure appropriate infection control practices (handwashing and/or use of hand sanitizer) for two residents (R48, R9) out of four observed for medication administration. This deficient practice has the potential for spread of infection that could potentially affect all residents residing in the D Hall.

Inspectors wroteThis citation pertains to Intake Number MI00145053. Based on observation, interview, and record review, the facility failed to ensure proper sanitizing and washing practices were used to clean dishes and utensils, and failed to provide proper hand washing facilities in the kitchen. This has the potential to affect all residents who eat from the kitchen.

Inspectors wroteThis citation pertains to Intake Number(s): MI00145115. Based on interview and record review, the facility failed to provide assistance with dressing for one (R801) of three residents reviewed for activities of daily living (ADLs).

Inspectors wroteThis citation pertains to Intake MI00142895. Based on interview and record review, the facility failed to permit one (R902) of one residents reviewed for discharge, to return to the facility following a transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate nursing staff to meet resident needs (including for Resident 17, R18 and R40), resulting in complaints of delay in care and meal delivery. This deficient practice has the potential to affect all residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure handrails in main hallways were maintained in a safe condition, and ensure a fully functioning heating system to maintain comfortable temperatures (for residents R18, R25, R19, R29, R251, R250, R249), which affected multiple residents residing on the A, B and C hallways.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure medications were consistently administered according to professional standards of practice for three (R's 249, 18 & 25) of three residents reviewed for professional standards of practice for nurses.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were properly labeled, stored and secured in one medication cart and three treatment carts of two medication carts and two medication storage rooms reviewed for medication labeling and storage.

Inspectors wroteThis citation pertains to intake #MI00141722 Based on interview and record review, the facility failed to ensure an environment free from physical restraints for one resident (R299) of one resident reviewed for Restraints.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to consistently provide bathing and grooming needs for one dependent resident (R249) of two residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure treatment was provided for a venous ulcer for one resident (R7) of one residents reviewed for non-pressure wound care, resulting in the potential for the wound to deteriorate/worsen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions to prevent injury from falls were in place for one resident (R3) of three residents reviewed for accidents/hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure catheter care was completed per plan of care and coordination of surgical follow-up for one (R25) of two residents reviewed for urinary catheter care.

Inspectors wroteBased on observations and interviews, the facility failed to provide consistent professional standards of practice regarding colostomy care for one (R249) of one resident reviewed for colostomy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure freedom from significant medication errors for one two residents (R#'s 705 and 706) of four residents reviewed for medications, resulting in R705 receiving R706's narcotic medications requiring the use of narcan (an opioid reversal treatment).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure built-up utensils were provided during meals for one resident (R3) of five residents reviewed for dining.

Inspectors wroteBased on interview and record review the facility failed to educate, offer and/or maintain the COVID-19 vaccination status for one staff (Certified Nursing Assistant - CNA K) of one staff reviewed for the COVID-19 vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to timely address an infestation of ants in the room occupied by R18, resulting in uncomfortable living conditions.

Inspectors wroteThis citation pertains to intake MI00142175 Based on observation and interview, the facility failed to maintain the heating units on the C hall, resulting in cold ambient air temperatures in the building and resident complaints.

Inspectors wroteThis citation pertains to intake #MI00139331 Based on interview and record review, the facility failed to ensure services met professional standards for medication administration and proper disposal of a fentanyl pain patch for one resident (R502) of two residents reviewed for administration and disposal of fentanyl patches, resulting in verbalized complaints and feelings of frustration.

Inspectors wroteThis citation pertains to intake #MI00138844. Based on observation, interview, and record review, the facility failed to ensure timely answering of a call light for one resident (R501) of three residents reviewed for call lights, resulting in complaints of frustration and unmet resident care needs.

Inspectors wroteThis citation pertains to intake #MI00138844 Based on observation, interview and record review, the facility failed to ensure a transportation to an outside consultation appointment for one resident (R501) of three resident's reviewed for outside appointments, resulting in the cancellation of the appointment and feelings of frustration.