Mission Point Nursing & Physical Rehabilitation of

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 15 sampled residents (R3, R51, and R69).

Inspectors wroteBased on interview and record reviews the facility failed to notify the responsible party of changes in conditions and treatment for one Resident (R5) of fifteen residents reviewed. Findings Resident #5 (R5) Review of the Electronic Medical Record (EMR) reflected R5 admitted to the facility 3/11/2018 with diagnoses that included: Traumatic Brain Dysfunction, Aphasia (inability or difficulty speaking), and Hemiplegia (weakness or paralysis on one side). Review of the Minimum Data Set (MDS) dated [DATE] reflected R5 was severely cognitively impaired. The EMR admission Record reflected Primary Contact (PC) K was the Guardian for R5. On 7/16/2025 at 11:16 AM a telephone interview was conducted with PC K who reported the facility had not always informed her of changes in status and care for R5. PC K reported several months ago she contacted the facility for an update on R5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and implemented for 2 of 15 residents (Resident #40 and #5) reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 2 of 15 residents (Resident #40 and #55) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to 1.) ensure insulin was administered and monitored following the provider order and 2.) ensure abnormal blood sugar results were reported to the provider for 3 of 15 residents (Resident #40, #10, and #64) reviewed for insulin administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care of a Continuous Positive Airway Pressure (CPAP) device for one Resident (R15) of fifteen residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications were properly dispensed and documented for 3 of 15 residents (Residents #2, #4, and #25) reviewed for controlled medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents (R52 and R60) observed during the medication administration task, resulting in a medication error rate of 6.66% (2 errors of 30 medications administered).

Inspectors wroteBased on observation and interview, the facility failed to properly label medications in 1 of 2 medication carts (Northeast/ Northwest Split Medication Cart) observed for medication storage.

Inspectors wroteThis citation pertains to intake #1239234:Based on observation, interview, and record review, the facility failed to ensure a clean environment for 2 residents (R7 and R17) reviewed for environmental concerns.

Inspectors wroteBased on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an appropriate size drinking cup to 1 resident (R16) of 1 Resident reviewed for reasonable accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an allegation of misappropriation to the state survey agency for 1 of 3 residents (R20) reviewed for abuse and misappropriation, resulting in the potential for abuse and misappropriation to go undetected, underreported, and not investigated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care for 1 (Resident #8) of 2 residents reviewed for Activities of Daily Living (ADL) care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide meaningful activities for 2 Residents (R7 and R16) of 2 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply hand splints for 1 (Resident #8) of 1 resident reviewed for contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were not in 1 of 2 medication carts inspected (Northwest Medication Cart) and failed to secure 1 of 4 medication carts (Southwest Medication cart).

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 2 of 60 facility residents [R34 and R46), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R4 and R7) of 2 residents reviewed for hospice care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean a glucometer per the manufacturer's instructions for 2 of 2 residents (R28 and R37) reviewed for blood glucose testing, resulting in the potential for the spread of infection and disease.

Inspectors wroteThis Citation pertains to Intake Number MI00143327. Based on observation, interview, and record review the facility failed to ensure the safety of one facility resident (Resident #6) who did not have full decision-making capabilities which resulted in the potential for elopement from the facility for the resident and all cognitively impaired residents.

Inspectors wroteThis Citation pertains to Intake MI00142054 Based on interview and record review the facility failed to ensure that staff had the necessary training and qualifications to hold the position of Activities Director.

Inspectors wroteBased on observation, interview, and record review, the facility to failed to ensure resident needs were met in a timely manner for 2 residents (Resident #28 and #314), reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide quality care for 1 resident (Resident #314), resulting in the loss of the resident's prescribed eye drops and subsequent failure to administer the eye drops per physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing and equipment were properly maintained in accordance with the facility policy and procedure for two facility Residents (Resident #56 (R56) and R34) resulting in the potential for respiratory infection for all facility residents that require the use oxygen devices.