North Pointe Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #9) reviewed for oxygen orders. The facility failed to ensure Resident #9 was receiving oxygen at 2-4 liters per minute as ordered by the physician. This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #39) reviewed for medication errors. The facility failed to hold Resident #39's Carvedilol and Hydralazine per the recommended and prescribed heart rate parameters on 06/01/26, 06/04/26, 06/08/26, 06/12/26, 06/13/26, 06/14/26, 06/15/26, 06/16/26, 06/17/26, 06/20/26, 06/21/26, 06/22/26, and 06/24/26. This failure could place residents who receive blood pressure and pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, and potential hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two of five residents (Resident #1 and Resident #2) reviewed for supervision. 1.) The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1, who was known to have confusion and wandering behaviors, first exited from an exterior door of the facility on 04/01/25. The facility failed to provide adequate supervision, and Resident #1 eloped from the facility on 09/06/25. 2.) The facility failed to ensure the Wander Guard system (an electronic system that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) utilized for Resident #2 was in proper working order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted her on 04/29/25 in Resident #3's room. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 18 residents (Residents #5, #20, and #34) reviewed for ADLs. 1. The facility failed to ensure Resident #20 and Resident #5's fingernails were cleaned and cut. 2. The facility failed to ensure Resident #34 received regular oral care. This failure had the potential to affect residents by placing them at risk for poor personal hygiene, decreased self-esteem, and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #9 and #29) reviewed for quality of care. The facility failed to ensure Resident #9 and #29 wore their compression stockings, used to prevent swelling and blood clots, as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater, 3 errors of 33 opportunities for errors leading to 9.09% medication error rates, for two of four staff (LVN D and MA F) observed for medication pass. The facility failed to ensure MA F administered the correct dose of 500mgs vitamin B12 for Resident #19. The facility failed to ensure LVN D administered all the crushed medication in the medication cups without leaving residue for Resident #105. These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for tube occlusion, not receiving the correct dose of medication, and those that took orally not getting intended therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one of 18 residents (Resident #36) reviewed for resident rights. The facility failed to ensure Resident #36 was treated with dignity and respect when she asked CNA C to dress her. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/05/25 and ended on 03/06/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 1 (Resident ##9) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #9's compression stockings. This failure placed resident at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #34) reviewed for foot care. The facility failed to ensure foot care, specifically trimming of toenails, was provided for Resident #34. This failure could result in residents developing fungal infections or other podiatric problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #105) reviewed for intravenous fluids. The facility failed to ensure Resident #105's intravenous tubing was labeled with the date and initials. The failures could affect residents by placing them at risk for infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents (Resident #10) on one hall reviewed for storage of medications. The facility failed to ensure an Amoxicillin tablet (an antibiotic) was not left at Resident #10's bed side unsupervised on 04/15/25. This failure could place residents at risk of consuming unsafe medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintain medical records on each resident that are complete and accurately documented for 1 of 1 residents (Resident #105) reviewed for respiratory care. The facility failed to document on Resident #105's MAR/TAR showing that the resident's oxygen tubing was changed on Sunday as ordered by the physician. This failure could affect residents with respiratory therapy and could lead them to lack of care including possible infection by not following the physician orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, or misappropriation of resident property for 1 of 3 residents (Resident #1) reviewed for abuse. CNA A was witnessed to have spoken in a verbally abusive manner about Resident #1 This failure could cause residents to have decreased feelings of self-worth. The noncompliance was identified as past noncompliance that began on 07/10/24 and ended on 07/10/24. The facility had corrected the noncompliance before the state surveyor entered. No plan of correction needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Residents #1, #6, and #7) reviewed for quality of care, in that: 1. The facility failed to prevent Resident #1's wound from increasing in size. Resident #1's Stage 3 coccyx wound measured 5 cm x 1.5 cm x 0.1 cm on 09/03/24 and increased in size to 12 cm x 10 cm x 0.1 cm when last seen by the WMD on 09/10/24. 2. The facility failed to ensure that Resident #6's low air loss mattress pump was plugged in. 3. The facility failed to ensure that Resident #7's low air loss mattress pump had the correct settings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Residents #6, #8, and #9) reviewed for quality of care. 1. The facility failed to ensure Resident #6, Resident #8, and Resident #9 had an indwelling urinary catheter strap in place to prevent pulling or tugging on 09/22/24. 2. The facility failed to provide Resident #6, Resident #8, and Resident #9 a privacy cover for the indwelling urinary catheter drainage bags on 09/22/24. 3. The facility failed to ensure Resident #8's indwelling urinary catheter was kept off the floor on 09/22/24. These failures could place residents at risk for discomfort, urethral trauma, loss of dignity and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 17 residents (Residents #2, #3, #4, and #5) reviewed for infection control. 1. The facility failed to ensure LVN A, MA, and Activity Director monitored residents to ensure they were not exposed to infections during lunch service when Resident #2 was serving lemonade and coffee to residents without proper hand sanitation. 2. The facility failed to ensure Resident #5 did not move around the dining room as he asked other residents for their dinner rolls. This failure placed residents at an increased risk of exposure to infections to include COVID- 19, decreased quality of life, or hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one of two residents (Resident #1) reviewed for suicidal ideation. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. The failure placed residents at risk for neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one of two residents (Resident #1) reviewed for neglect. The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of five residents (Resident #1) reviewed for baseline care plans. The facility failed to establish a base line care plan to address Resident #1's diagnosis of suicidal ideation when she admitted to the facility. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 6 residents (Resident #18) reviewed for nutritional status. The facility failed to ensure Resident #18 consistently received weekly weights as prescribed by the Dietitian on 02/16/24. These failures could place residents at risk for continuing to lose weight.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of three residents (Resident #47)reviewed for contracture management. The facility failed to apply rolled wash cloths to Resident #47's hands for contracture (a permanent tightening of the muscles) management. This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures and a decline in physical capabilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #53) reviewed for accidents. The van driver failed to properly restrain Resident #53's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis on 03/05/24. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and expired medications were removed for one of four medication carts (200 Hall medication cart) reviewed for labeling and storage. 1. The facility failed to ensure Vitamin B12 vials that were expired were removed from the 200 Hall medication cart. 2. The facility failed to ensure insulin was dated with the open dates on the 200 Hall medication cart. These failures placed residents at risk of receiving medications that were ineffective due to having expired vitamin B12 vial on the cart and not putting an opening date on insulin pens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 24 residents (Resident #38) reviewed for resident call system. The facility failed to ensure Resident #38 had a working call light. This failure could have placed residents at risk of being unable to obtain assistance when needed.