North Pointe Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three residents sampled for abuse investigation (Resident 2) from physical abuse, when Resident 1 pushed Resident 2 and Resident 2 landed on the floor face down, sustaining a fracture to her right upper arm (humerus) and a right hip (femoral) fracture. This failure resulted in Resident 2 experiencing physical pain and had a significant decline in functional status from being totally independent, to requiring maximum assist (where staff provide most of the activities for the resident) for mobility and with daily activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an individualized care plan for one of three sampled residents (Resident 1), when interventions to mitigate Resident 1's aggressive behaviors of hitting and striking at other residents were not put in place. This failure potentially contributed to Resident 1 pushing Resident 2, and as a result Resident 2 sustained fractures to upper arm and hip in addition to physical pain. This failure also placed other vulnerable residents residing in the facility at risk for physical harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the Physician Orders for Life-Sustaining Treatment (POLST, a medical order that tells healthcare providers what treatments a person does or does not want) for one of four sampled residents (Resident 1) when Cardiopulmonary Resuscitation (CPR- an emergency procedure that involves chest compressions and rescue breathing to a person whose heart has stopped beating) was initiated on Resident 1 despite Resident 1's documented orders to not perform CPR.This failure violated Resident 1's right to have their treatment choices respected and implemented.

Inspectors wroteBased on interview, and record review the facility failed to ensure the facility was free from abuse for one of six sample residents (Resident 1) when Resident 1 was pushed to the floor by Resident 2. This failure resulted in Resident 1 landing on the floor and experiencing left hip pain. During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted January of 2025 with a diagnosis of Dementia (a decline in thinking, memory, reasoning and ability to make decisions). A review of Resident 1 Minimum Data Set (MDS- an assessment tool) dated 3/3/25 indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's progress note, dated 2/6/25 indicated Resident 3 reported that Resident 1 got pushed by Resident 2. The progress note indicated Resident 1 was laying on his back and when Resident 1 started walking he verbalized his left hip area hurt. [...]

Inspectors wroteBased on interview, and record review the facility failed to report allegations of abuse to the Department as required by the regulations when one of six sample residents (Resident 1) was pushed to the floor by Resident 2. This failure to report allegations of abuse resulted in delay in conducting investigation by the Department. During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted January of 2025 with a diagnosis of Dementia (a decline in thinking, memory, reasoning and ability to make decisions). A review of Resident 1 Minimum Data Set (MDS- an assessment tool) dated 3/3/25 indicated Resident 1 had moderate cognitive impairment (moderate problems with thinking and memory). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility residents were free from accident and safety hazards when a personal items (one broken pair of glasses, dentures, and hearing aides) cart was left unlocked in the hallway for a total census of 160. This failure had the potential for residents to access the cart without staff supervision. During an observation on 3/27/26 12:40 p.m. in hallway near room [ROOM NUMBER], the Personal Items cart was observed with three nursing staff present. The 3 nursing staff left the cart unlocked. During an observation on 3/27/25 at 12:45 p.m. at the personal items cart, the cart was unlocked and three residents were observed walking by the cart. During a concurrent observation and interview on 3/27/26 at 12:47 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report injuries of unknown origin (IUO) to the Department as required by the regulations for one of four sampled residents (Resident 1) when Resident 1 was noted with a scald injury (a type of burn injury caused by hot liquids that causes damages to the skin and tissue) to his right hand of unknown origin/cause. This failure resulted in a delay of investigation by the Department. A review of Resident 1's clinical record indicated Resident 1 was admitted in June of 2024 with a diagnosis of Alzheimer's Disease (a progressive irreversible brain disorder that destroys memory and thinking skills over time). A review of Resident 1's MDS (minimum data set - an assessment tool) dated 12/22/25 indicated Resident 1's score was NA indicating no cognition score could be determined. During an observation on 3/4/26 at 11:55 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services and implement measures for the prevention of pressure injuries (painful wounds caused as a result of prolonged pressure or friction) for two of 37 sampled resident (Resident 4 and Resident 32), who were at risk for skin injuries when, Resident 4 obtained a skin tear (a traumatic wound of the top layer of skin) from the use of bolster (part of a mattress cover with raised foam edges on each side of the bed to prevent resident from rolling out of bed), did not implement interventions addressing use of bolster, did not document accurate assessments of the wound every shift as indicated by resident's care plan; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was labeled, prepared, stored, served, or distributed in accordance with professional standards of food safety when:Kitchen utensils were stored wet in the clean and ready-to-use bin;unlabeled, undated, opened food items were found in kitchen area;metal pans were stacked wet at the clean and ready-to-use area;mislabeled food items were found in resident refrigerator in medication room; andunlabeled, undated food items were found in Resident 90's room. These failures increased the potential for food-borne illnesses among the census of 157 residents.

Inspectors wroteBased on interview and record review, the facility failed to identify trauma triggers for six out of 37 sampled residents (Resident 2, Resident 9, Resident 29, Resident 113, Resident 93, and Resident 152) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) or identified traumatic events. This failure had the potential for the residents to experience re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and possible increased symptoms such as restlessness, irritability and social withdrawal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 157 when:1. Two facility staff did not wear required personal protective equipment (PPE) when transferring, assisting with personal care, and handling the foley catheter (a tube inserted through the urethra into the bladder to drain urine) for Resident 38 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. A clean resident's personal items delivery cart had a thick layer of dust on the inside surface;3. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one out of 37 sampled residents' (Resident 42) right to be free from elderly financial abuse by a family member/legal representative when Resident 42 experienced financial abuse by her sister who was also her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves). This failure resulted in Resident 42 experiencing financial abuse, and possible serious psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical restraints (physical devices, or equipment that restricted resident movement or ability to get out of bed including bed rails) for one of 37 sampled residents (Resident 149), when the facility did not:Obtain a physician's order for the use of bed rails; 2. Obtain approval from resident or resident's representative (RP) for the use of bed rails; 3. Conduct bed rail assessment prior to placing the quarter side rails and, 4. Develop a care plan to mitigate the risks for entrapment (being caught in or trapped). These failures placed Resident 149 at increased risk for complications of restraint use such as decline in functioning and potential to cause physical harm from entrapment.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not reported to the state agency, local ombudsman, adult protective services, and law enforcement officials. This failure resulted in a delayed investigation of the suspicion of Resident 42's financial abuse and placed Resident 42 at risk of experiencing further financial abuse, and possible serious psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not investigated. This failure resulted in Resident 42 experiencing further financial abuse, and possible serious psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to update and revise resident's care plans (documents that summarizes resident's needs, goals, and care/treatment) for one of 37 sampled residents (Resident 4), after the physician discontinued orders for resident's splint (a device to immobilize joint) and fluid restriction (means limiting person's intake of liquids due to health conditions). These failures increased the potential to result in confusion in the delivery of care and services to Resident 4 and the resident continued to receive care and treatment that was discontinued. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 37 sampled residents (Resident 13 and Resident 146) were assisted with nail care as part of his Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 13 and Resident 146 had long fingernails with blackish substance underneath. This failure had the potential for Resident 13 and Resident 146 to sustain skin injury and/or to acquire an infection and not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of 37 sampled residents (Resident 38) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P when Resident 38's foley catheter (a tube inserted through the urethra into the bladder to drain urine) bag was left on the floor. This failure had the potential for Resident 38 to develop infection and possible foley catheter complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for 1 of 8 sampled residents when:Resident 130's oxygen tubing/nasal cannulas (a medical device connected to an oxygen source used to deliver supplemental oxygen directly into the airways) were not labeled with the date it was first used. This failure had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 130.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 37 sampled residents (Resident 146) when Resident 146 who was on 2 gram (gm/g- unit of measurement) low salt diet (a dietary restriction that limits the intake of salt to 2 grams for the whole day) received a salt packet during the 1/6/26 lunch meal. This failure had the potential to negatively affect Resident 146's medical condition and for Resident 146 not to achieve his highest practicable well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and homelike environment was provided when horizontal blinds in three (room [ROOM NUMBER], 26 and 35) of 53 rooms were broken, for a census of 157. This failure had the potential to cause injury and unsafe condition to vulnerable residents residing in these rooms. During an observation conducted on 1/6/26 at 9:14 a.m., the horizontal blinds in room [ROOM NUMBER] were broken. There were 5 residents in this room. Further observation was conducted on 1/6/26 at 1:16 p.m., the horizontal blinds in room [ROOM NUMBER] had broken edges. There were 4 residents in this room. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 1/6/26 starting at 1:17 p.m., the ADON confirmed the blinds in room [ROOM NUMBER] and room [ROOM NUMBER] were broken. [...]

Inspectors wroteBased on observation, interview, and record review, six out of 53 rooms (Rooms 15, 16, 22, 23, 24, and 25) had more than four residents in each room. This failure had the potential to impact resident's care and privacy. During the Entrance Conference with the Administrator (ADM) on 1/6/26 starting at 8:17 a.m., the ADM stated the facility will renew existing room waiver (specific regulatory flexibility) to have more than four residents in six rooms (Rooms 15, 16, 22, 23, 24, and 25). During a review of the facility letter, dated 1/6/26, the letter indicated six rooms would accommodate more than four residents per room. The letter further indicated, These rooms all provide adequate space for resident care, storage, as well as privacy. During multiple observations conducted on 1/6/26 starting at 8:45 a.m., there were 5 residents in rooms 22, 23, 24, and 25. [...]

Inspectors wroteBased on observation, interview, and record review, two out of 53 resident rooms (room [ROOM NUMBER] and 16) did not meet the minimum requirement of 80 square feet (sq ft; unit of measurement) per resident. This failure had the potential for residents in rooms [ROOM NUMBERS] to not have enough space for care and privacy which could impact the residents well being. During an initial tour of the facility on 1/6/26, starting at 9:01 a.m., rooms [ROOM NUMBERS] were observed to have six beds in each of the rooms. During observation, the rooms were uncluttered, residents were able to move in and out of the rooms, and there was enough space for beds, wheelchairs, side tables, and other residents' care equipment. During an interview on 1/6/26 at 9:01 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by Resident 2 for one of three sampled residents (Resident 1) when Resident 2, who had a history of verbal threats struck Resident 1 in the face. This failure resulted in Resident 2 striking Resident 1 causing lacerations to Resident 1's eyebrow, nose and cheek, caused pain, and had the potential for Resident 1 to experience emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to protect one of four (4) sampled residents' (Resident 1) right to be free from physical abuse when a facility staff member pushed Resident 1 on his face causing him to fall on the ground. This failure resulted in an emergency hospital transfer of Resident 1 for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse, when Licensed Nurse 1 (LN 1) hit resident in the face causing face abrasions. This failure resulted in Resident 1 experiencing unnecessary pain, fear, and mental anguish and had the potential to cause further psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote, maintain, and treat five of 37 sampled residents (Resident 77, Resident 119, Resident 44, Resident 21, and Resident 6) with respect and dignity when: 1. Resident 77 was not provided with privacy when receiving phone calls; 2. Resident 119's requests were ignored; 3. Residents were referred to as feeders and residents were not asked if they wanted to wear a bib during a meal; 4. Certified Nursing Assistant (CNA) 6 was standing while feeding Resident 21 and 44; and 5. Resident 6 was not provided with privacy during medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the POLST (Physician Orders for Life-Sustaining Treatment which include code status with instructions on what to do if the resident had no pulse and stopped breathing) forms were completed and updated when: 1. Two of 37 sampled residents' (Resident 3 and 44) POLST forms were not signed and completed; and 2. Two of 37 sampled residents' (Resident 104 and 111) code statuses were not updated in their EMR (Electronic Medical Record) after new POLSTs were put in place. These failures had the potential to result in the facility not acting in accordance with residents' wishes and following physician orders in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment was provided for three of 37 sampled residents (Residents 18, 41, and 74), when there were no clocks available in the residents' rooms. This failure increased the potential for the residents not attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately maintain pharmacy services for two out of a census of 156 when: 1. A controlled drug (medication that may be abused or cause addiction) destruction record log was inaccurate. 2. Two tablets of lacosamide (a medication given for seizures) were in one single dose unit of the medication card and not accounted for by the nursing staff. This failure had the potential to cause inaccurate accountability of controlled medications and the potential to result in diversion of the residents' medication.

Inspectors wrote2. A review of Resident 150's admission Record indicated Resident 150 was admitted in June 2024 with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and thinking skills) and dementia with behavioral disturbance. Resident 150's MDS, dated [DATE] indicated, severe cognitive impairment. During a review of Resident 150's clinical record included the following documents: A physician's order, dated 8/28/24, indicated an order for risperidone (an antipsychotic), 1 mg (milligrams, a unit of measurement)/1 ml (milliliter, a unit of measurement) solution, Give 0.5 mg by mouth one time a day. An MDS Section E, dated 6/25/24, indicated that Resident 150 had no potential indicators of psychosis. During a review of Lexicomp (a nationally recognized drug information resource) indicated, ALERT: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%) when two medication errors occurred out of 29 opportunities during medication administration for two residents (Resident 6 and Resident 71) of five selected residents during medication pass. This failure resulted in medications not given in accordance with the physician's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 5 selected residents during medication pass (Resident 6) was free of significant medication errors when a licensed nurse administered insulin aspart, (short acting injectable medication used to lower blood sugar level) not in accordance with physician orders. This failure put the resident at risk for suffering adverse consequences from the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled, when: 1. Medications were not properly stored per manufacturer instruction, 2. Expired and discontinued medications were available for resident use, 3. Loose pills and loose medical supplies were found in the drawers and the back of medication cart and 4. Refrigerated medications were not stored in accordance with facility Policy & Procedure (P&P). These deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored.

Inspectors wroteBased on observation, interview and record review food storage, service and distribution were not completed in accordance with professional standards when: 1. Kitchen vents, fans, and floors were found dirty and/or dusty, 2. Worn food preparation equipment was kept in storage and not discarded when it could no longer be sanitized, 3. Foods in storage found expired, open to the environment, and/or improperly labeled, and 4. Kitchen staff were unable to demonstrate how to test for proper sanitation concentration levels. These failures had the potential to cause food borne illness for the 155 residents receiving facility prepared foods.

Inspectors wrote4. During a concurrent inspection of medication cart B and interview on 9/10/24 at 11:00 a.m. with Licensed Nurse (LN) 4, food items (a sandwich and an opened pudding) were found stored in the medication cart. LN 4 confirmed the finding and stated the food items should not be stored in the medication cart. LN 4 acknowledged that medication carts should only be used for medications. During a concurrent inspection of medication cart B and interview on 9/10/24 at 11:05 a.m. with LN 4, 3 nail clippers were identified and stored next to eyedrops. LN 4 confirmed the finding and stated that the nail clippers should be clean. LN 4 acknowledged that medication carts should only be used for medications. During an interview on 9/11/24 at 2:40 p.m. with the DON, the DON stated all food items should be in the ice bucket on top of the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 37 sampled residents (Resident 119), who was observed with cold and allergy nasal spray at the bedside, was assessed and had an order to self-administer medication. This failure had the potential to result in overmedication for Resident 119 and exposed other residents to accidental access to the nasal spray.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's right to privacy and confidentiality of personal and medical records for a census of 156 residents when computer screen that showed confidential personal and medical information was left unsecured. This failure had the potential to result in unauthorized access of residents' personal and medical information.

Inspectors wroteBased on interview and records review, the facility failed to ensure one of 37 sampled residents (Resident 119) received treatment and care in accordance with professional standards and practice, when the facility did not follow up on resident's request for allergy medication for six days. This failure resulted in a delay of Resident 119's allergy medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 37 sampled residents (Resident 138) received necessary services to ensure proper grooming when Resident 138 had black material under her nails. This failure had the potential to cause infection to Resident 138 due to poor hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for one of 37 sampled residents (Resident 44) when the activities care plan was not followed. This deficient practice had the potential to affect the resident's psychosocial well-being, self-worth and meaning in life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to maintain vision for one of 37 sampled residents (Resident 143), when Resident 143 was not sent to the hospital for an acute onset vision loss. This failure had the potential to cause deterioration of vision leading to increased fall risk and greater loss of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 38) received care and services in accordance with the physician order, when the staff failed to place the hand roll to the resident's right hand. This failure had the potential for Resident 38 to experience a further decline in use of her right hand and loss of ability to feed self independently, and result in skin breakdown.

Inspectors wroteBased on observation, interview, and record review, six of 53 resident rooms (room [ROOM NUMBER], 16, 22, 23, 24, and 25) accommodated more than four residents in each room.

Inspectors wroteBased on observation and interview, two of 53 resident rooms (15 and 16) did not meet the minimum requirement of 80 square feet (sq ft; unit of measurement) per resident.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of six sampled residents (Resident 2) from abuse when the hospitality aide [HA] got upset and slapped Resident 2 on the cheek repeatedly. This failure had the potential to cause injury, fear and distress to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was implemented and monitored for effectiveness for one of six sampled residents (Resident 1) when there was no documented evidence Resident 1's hip protectors were applied as directed by the care plan to minimize the impact of falls. This failure decreased the facility's potential to minimize the serious consequences of falls for the resident. Additionally, Resident 1 had a witnessed fall and sustained a hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was implemented and updated for one of 5 sampled residents (Resident 1) when Resident 1's ileostomy (a surgically created opening in the abdomen to allow waste to leave the body through a new skin opening called the stoma) bag was leaking. This failure resulted to increased redness and irritation to Resident 1's ileostomy site and surrounding skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect 2 of 6 sampled residents (Resident 2 and Resident 4) from abuse when: 1. Resident 1 pulled Resident 2's walker causing him to fall, and 2. Resident 3 punched Resident 4 on the face during an altercation. These failures resulted in Resident 2 sustaining a right intertrochanteric fracture (broken hip bone) and underwent hip arthroplasty (a surgery to replace the broken hip bone with an artificial implant) and Resident 4 had the potential to experience physical injury and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the fluid intake for one of 8 sampled residents (Resident 8) was accurately monitored and communicated to the physician. This failure increased the potential for Resident 8 to experience signs of fluid overload (too much fluid in the body) such as swelling of the feet and weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from mental abuse by facility staff for one of four sampled residents (Resident 1) when facility staff took a picture of Resident 1 with an unsecured facility cell phone while Resident 1 was lying the floor with his pants around his ankles, without undergarments, and trying to cover his naked buttocks with the edge of his nightshirt. This failure portrayed Resident 1 in an undignified manner and had the potential for multiple staff members, other residents and family members, to view the photograph, which could cause mental anguish to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the responsible party (RP) and physician for one of four sampled residents (Resident 1) when Resident 1 had an unwitnessed fall, which resulted in bleeding and an injury to the lip. This failure delayed prompt medical monitoring, treatment and left the family unaware of the situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was monitored timely for neurological changes (injury or changes that result from an injury to the head that affect the brain) after an unwitnessed fall. This failure had the potential for Resident 1 to have neurological deterioration that was not assessed or monitored by staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the representative or Responsible Party (RP) was informed of the skin discoloration for one resident (Resident 1), for a census of 155. This failure resulted in Resident 1's RP not being informed of the skin changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to ensure safety for 2 of 3 sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had a verbal and physical altercation in the back yard. This failure resulted in Resident 1 sustaining a scratch on the cheek and Resident 2 had skin tear to left hand.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control standards of practice for Resident 1 when the indwelling catheter (tube placed into bladder to collect urine) bag was lying on the floor under resident's bed. This failure decreased the facility's potential to prevent the spread of infection.

Inspectors wroteBased on observation and interview, six resident bedrooms (rooms 15, 16, 22, 23, 24, and 25) accommodated more than four residents per room.

Inspectors wroteBased on observation and interview, two resident rooms (rooms [ROOM NUMBERS]) did not meet the minimum requirement of 80 square feet (sq ft- unit of measurement) per resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain nail care for one Resident (Resident 8) of eight sampled residents, when Resident 8's toenails were long, cracked and unevenly trimmed. This failure decreased the facility's ability to assist Resident 8 to reach his highest practicable level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of four sampled residents (Resident 1), when baseline care plan did not identify the resident as an elopement risk and there was no frequent monitoring and supervision included in the care plan interventions. This failure resulted in Resident 1 leaving the facility and not attaining his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety monitoring and supervision for one of four sampled residents (Resident 1), when the resident jumped off the fence of the facility and has not been located. This failure had the potential to result in Resident 1's harm, including accidents, falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive person-centered care plan for 1 of 2 high risk elopement residents (Resident 1), when interventions to prevent elopement were not developed and implemented for Resident 1. These failures resulted in an avoidable elopement from a secured locked facility, (locked memory care units provide a place for residents with any type of dementia/memory problems to live safely, with increased supervision and support as their diseases progress), compromising the health and safety of Resident 1.

Inspectors wroteBased on interviews and record review, the facility failed to provide the necessary supervision Resident 1 required to ensure his safety when Resident 1 eloped from the facility's Behavior Intervention Monitoring Program Room (BIMP, a program designed to provide supervision of specific behaviors which are based on an evaluation from a psychiatrist). This failure resulted in Resident 1's elopement and increased the potential for physical injury and psychosocial harm to Resident 1 during his unsupervised time away from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were adequately trained and had competency skill sets to provide services to ensure the safety of one of two residents, (Resident 1), when Resident 1 had signed out of the Behavioral Intervention Monitoring Program (BIMP) room, had no supervision, and eloped the locked facility. This failure had the potential for more than minimal harm for one of two residents, (Resident 1), when an unsupervised elopement occured in a locked facility by Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully establish and implement an infection prevention and control (IPC) program for a census of 108 residents when: 1. There was no documented evidence of an IPC plan; 2. There was no documented evidence of a system of active infection surveillance for all types of infections in the facility to prevent the occurrence or spread of infections; 3. There were no investigations into the potential causes or contributing factors of facility-acquired infections; and, 4. There was no documented evidence of a system for process surveillance used to develop the facility assessment and IPC plan. These failures increased the potential for residents to have acquired infections that could have caused significant pain and discomfort, and could have had significant adverse consequences.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure two residents (Resident 96 and Resident 4) out of a sample of 33 were treated with respect and dignity when: 1a. A Licensed Nurse (LN) 1, without notifying Resident 96 beforehand, removed Resident 96's covers exposing him; 1b. A Certified Nurse Assistant (CNA) pulled Resident 96 in his recliner chair from behind into his room, and fed him his dinner while standing over him from behind; and, 2. Staff gave Resident 4 a wash basin to store his belongings instead of providing the resident a nightstand. These failures resulted in Resident 96 and Resident 4 receiving undignified care and had the potential to negatively effect their psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one resident (Resident 17) in a sample of 33 had an environment that was free from hazards when staff left a pool of urine on the floor under Resident 17's bed with an electrical cord running through it. This failure had the potential to result in an accident leading to potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide basic furniture to meet the needs of one resident (Resident 4) in a sample of 22 when Resident 4 did not have a nightstand to store his personal items. This failure resulted in Resident 4 storing his items in a plastic wash basin on the floor.

Inspectors wroteBased on observation and interviews, six resident bedrooms (rooms 15, 16, 22, 23, 24, and 25) accommodated more than four residents per room.

Inspectors wroteBased on observation and interviews, three resident rooms (rooms [ROOM NUMBER]) did not meet the 80 square feet (sq ft) minimum requirement per resident.