Point Lookout Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored under sanitary conditions when potentially hazardous food was not thawed using sanitary methods; when staff failed to check the temperature of potentially hazardous and food was not kept at the proper temperature on the steam table; and when dietary staff failed serve food under sanitary conditions when dietary staff touched ready-to-eat food items with bare hands. This had the potential to affect all staff and residents in the facility. The facility census was 85.1. [...]

Inspectors wroteBased on record review and interview, the facility failed to make individual financial record available to the resident or resident representative through quarterly statements and upon request when facility staff failed to provide 5 residents (Resident #1, #2, #3, #4, and #5) or their responsible party with reconciled quarterly resident trust fund statements. The facility census was 88. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the right of all residents to be free from misappropriation when resident personal funds of five residents (Resident #1, #2, #3, #4, and # 5) were used to make multiple unauthorized purchases. A sample of residents was reviewed in a facility with a census of 88. Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated November 2017, showed the following:-Each resident will be free from verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion;-Residents will be protected from abuse, neglect, and harm while at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff member employed as the Dietary Manager had the required certifications, education, or experience to meet the regulatory requirements. The facility census was 93. Review of the facility policy titled, Dietary Manager, dated 01/01/98, showed the following: -Minimum qualifications of high school diploma or GED equivalent; -Two years of experience in a supervisory capacity in related field; -Certified Dietary Manager. 1. During an interview on 10/21/24, at 10:05 A.M., the Dietary Manager said the following: -He/she had only been the manager for two years and had been a CNA/CMT previously; -He/she was not certified; -He/she was given a voucher to take a test, but that was four or so, administrators ago. He/she was not sure what happened to it; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed keep food safe from potential contamination or bacterial growth at all times when staff failed to air dry dishese before storage. The facility census was 93. 1. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Record review of the facility's policy, Nutrition and Dining Services Manual, Section 8, dated April 2011, showed the following: -Items are to be air dried; -No moisture can be found on any stacked item. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain a clean and comfortable environment when the facility staff failed to maintain all light fixtures, walls, floors, sinks, and ceilings in in the dining and kitchen areas clean and free of debris. The facility census was 93. Record review of the facility policy, Nutrition and Dining Services Manual, Section 10, dated April 2011, showed the following: -Specify days the cleaning schedule will be done; -Specify who is responsible to do the cleaning by shift and position; -Post the schedule prior to the beginning of each week; -The employee will initial in the column under the day the task is completed. 1. Observation on 10/21/24, at 10:00 A.M., of the main dining room showed the a light fixture above the serving counter covered in cobwebs. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to read administered tuberculosis (TB - a disease caused by germs that are spread from person to person through the air) skin tests in a timely fashion, per standards of practice, for three employees (Dietary Aide (DA) A, Licensed Practical Nurse (LPN) B, and Certified Nurse Aide (CNA) C. Facility had a census of 93. Review of the facility policy titled, Tuberculosis Control, not dated, showed the following: -Provide a tuberculin skin test to all employees during pre-employment procedures unless a previous reaction greater than 10 millimeters is documented; -An initial two step tuberculin skin test will be given; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two resident (Resident #39 and #85) who remained in the facility after discharge from Medicare Part A services. The facility census was 93. Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), undated, provided as the facility's policy, showed the following: -The SNF ABN provided information to the patient so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNF's must use the SNF ABN when applicable for SNF prospective payment system services (Medicare Part A); [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide services per standards of practice when staff failed to provide ordered restorative nursing services for three residents (Resident #6, #7, and #8) and failed to care plan restorative services for one resident (Resident #7) out of four sampled residents. The facility census was 83. Review of the facility's Restorative Nursing Manual, undated, showed the following: -The Restorative Nursing Program (RNP) is an integral part of maximizing the daily restorative care process for the residents; -The RNP is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at a temperatures that were palatable and appetizing for five residents (Resident #1, #2, #3, #4, and #5) who often ate in their rooms. The facility census was 83. Review of the facility policy titled, Food Temperatures, dated April 2011, showed the following: -Hot food should be at least 120 degrees Fahrenheit (F) when served to residents; -A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels; -Plate lowerators are functioning and turned on prior to the meal service according to manufacturer's direction; -Lowerators are not over-filled so that all items are being heated; -Food is not placed in the steam table more than 30 minutes before meal service; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) provided cares to three residents (Residents #1, #2, and #3) in an unrespectful and undignified manner when the CNA rushed residents, raised his/her voice at residents, and spoke in a disrespectful tone of voice when answering the residents' call lights. The facility census was 89. Review of the facility policy Resident Rights, undated, showed each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #1's face sheet (document with admission information) showed the following: -admission date of 12/01/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food safe from potential contamination when food items were not dated or labeled after opening, or were left open and exposed to absorb ice crystals and odors and when staff failed to keep the kitchen free of an accumulation of grime and debris. This had the potential to affect all residents who ate food from the kitchen. The facility census was 83. Record review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 3/4/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and homelike environment when staff failed to replace/fix ceiling tiles damaged by a water leak for one resident (Resident #10), failed to repair damage on two residents' (Residents #8 and #72) bedroom walls, and failed to change ceiling tiles that were stained from water leaks in the resident hallways and dining rooms. The facility census was 83. The facility did not have a specific policy pertaining to the repair of walls or ceiling tiles. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admission date of 03/04/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative regarding the facility's bed hold policy for five residents (Residents #8, #12, #17, #69, and #83) who were transferred out to the hospital. The facility census was 83. Record review of the facility's Bed Hold Guidelines (undated), showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Residents #8 and #79), who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene, including showers and nail care, out of a sample size of 23. The facility census was 83. Record review showed the facility did not have a policy available for showers. Record review of the facility provided undated policy, title Nails, Care of (Fingers and Toes), showed the following information: -Purpose to provide cleanliness, comfort, and prevent spread of infection; -The nursing assistant may perform nail care on the residents who are not at risk for complications of infection; -The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders for bed rail use for two residents (Resident #46 and #69); failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for two resident's (Resident # 23 and Resident #46); failed to obtain informed consent prior to the use side rails for two resident's (Resident #23 and Resident #46); failed to address the use bed rails in residents' care plans for two residents (Residents #12 and #46); failed to conduct an initial safety gap check for five residents (Residents #12, #23, #36, #46, and #69); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 83. Record review of the (undated) facility policy, titled Bed Rail Policy, showed the following: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while completing medication administration for 7 residents (Residents #10, #23, #35, #51, #55, #66, and #69). The facility census was 83. 1. Record review of the facility policy, titled Medication Administration, dated 2/7/13, showed the following information: -Medications are given to benefit a resident's health as ordered by the physician; -Staff should bring the cart to the resident room; -Knock on the door before entering the room; -Introduce yourself, call resident by name, and check picture ID in the medication book; -Wash hands; -Read the label three times before administering the medication; -Administer medication; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #10). The facility had a census of 83. The facility did not have a shower policy. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 Diabetes Mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/2023, showed the following: -Cognitively intact; -Independent with transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written transfer notice to the resident and/or resident's representative for two residents (Residents #17 and #69) who were transferred out to the hospital. The facility census was 83. Record review of the facility provided copy of the form letter being sent to a resident's responsible party, titled Emergency Transfer Notice, showed the following information: -The letter is to serve as your emergency notice of transfer from the facility due to the need for urgent medical care which cannot be met by the facility; -More information on the discharge process can be received from State Long Term Ombudsman and address and phone number listed; -The name and address of facility transferred to; -Phone number of the facility and administrator signature. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #70) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan for three residents (Residents #24, #36, and #39) of 18 sampled residents to reflect the residents' current care needs. The facility census was 83. Record review of the facility policy, titled Care Plan Comprehensive, with no date, showed the following: -An individualized care plan team with input from the resident, family, and/or legal representative will develop and maintain comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -A well-developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels; -Managing risk factors to the extent possible or indicating the limits of such interventions; -Addressing ways to preserve and build upon residents strengths; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective system to ensure a resident's choice of code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was readily accessible to staff and documented consistently throughout the medical record for one resident (Resident #10). The facility census was 83. Record review of the (undated) facility policy titled, Advance Directive, showed the following: -The facility will respect advance directives in accordance with state law. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff did not provide activities as scheduled and did not track attendance of activities to evaluate if activities needs were being met for two residents (Residents #10 and #13). The facility had a census of 83. Record review of the facility policy titled, Activity/Recreational Therapy Manual, last reviewed on 03/12, showed the following: -The purpose is for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. -To enhance the quality of the residents daily life; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for two residents (Resident's #39 and #13) out of 23 sampled residents. The facility census was 83. Record review of the (undated) facility policy titled, Criteria for Restorative Nursing Assistant (RNA) program, a section of the Restorative Nursing Manual, showed the following information: -Referral to the RNA program may be made by nursing, Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and physician, as well as through the Minimum Data Set (MDS- a federally mandated assessment completed by staff) process, Certified Nurses Aide (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, or ST, the referral to the RNA is made; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders to discontinue the use and care of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #36), failed to remove the catheter from the care plan and Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), and failed to document accurately when they charted the changing of catheter as completed when the resident no longer had a catheter. A sample of 23 residents was selected for review in a facility with a census of 83. Record review of the facility undated policy, titled Physicians Orders showed the following: -The following information is provided to assist staff in recording physicians' orders: -Foley catheter orders should include: -Why it is needed; [...]

Inspectors wroteBased on observation and interview, facility staff failed to post required nurse staffing total hours and failed to include the resident census in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. The facility census was 83. Record review showed the facility did not provide a policy regarding posting staffing hours. 1. Observation on 3/12/23 at 5:00 P.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/12/23, 3/13/23, and 3/14/23 with names of staff scheduled. 2. Observation on 3/13/23 at 9:54 A.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff checked one resident's (Resident #23) blood glucose level and administered a sliding scale dose of insulin 40 minutes after the resident ate his/her meal. Staff also failed to prime the insulin pen and hold the insulin dose for six to 10 seconds at the site of administration as recommended by the manufacturer to ensure the resident received the full and correct dose of insulin. The facility census was 83. Record review of the (undated) facility policy, titled Diabetic Infection Control, showed the following: -Insulin injection pens are for single resident use; -The policy did not address timing of blood glucose checks or priming insulin pens before injection or holding insulin pens after injection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for four residents (Resident #31, Resident #42, Resident #48, and Resident #75) out of 21 sampled residents. The facility census was 103. Record review of the facility's policy titled, The Restorative Nursing (RNA) Program, dated May 2006, showed the following information: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -The RNA program is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to update the care plan for one resident (Resident #58) when the resident returned from the hospital with a peripherally inserted central catheter (PICC) intravenous (IV) line for infusion of antibiotics due to an osteomyelitis (a bone infection) and cellulitis (an infection of the tissue), out of a selected sample of 21 residents. The facility's census was 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-entered from the hospital on 4/24/19; -Moderate cognitive impairment; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Functional limitation in range of motion to bilateral lower extremities; [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to identify, assess, and monitor one resident's (Resident #53) pressure ulcer and failed to follow appropriate infection control measures when cleaning one resident's (Resident #40) multiple pressure ulcers and failed to measure on resident's (Resident #40) pressure ulcers, according to professional standards, in a selected sample of 21 resident's. The facility's census was 103. Record review of the facility's pressure ulcer policy, dated March 2015, included the following information: -Purpose: To prevent and treat further breakdown of pressure ulcers; -Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; -Observe skin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate one resident with a history of falls (Resident #21) in a timely manner for the need of an assistive device when requested by the resident. The facility failed to assess and document one resident's (Resident #53) reported incident involving a mechanical lift. A sample of 21 residents was selected for review in a facility with a census of 103. Record review of the facility's policy titled Fall Precaution and Management and Guidelines, (undated) showed the following: -Objective to identify residents at significant risk of falls and provide for additional precautions to reduced or manage risk; -A resident will be placed on the fall precaution program when any of the following conditions exist: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an agreement with a dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) provider, failed to obtain a physician's order for dialysis before the resident received dialysis, and failed to consistently send and complete a dialysis communication form for one resident (Resident #253) in a selected sample of 21 residents. The facility's census was 103. 1. Record review of the facility's Dialysis, Care of a Resident Receiving policy, dated March 2012, showed the following sections: -Care of the AV (arteriovenous) shunt/fistula/grafts (abnormal connection or passageway between an artery and a vein); -Care of a subclavian (major arteries of the upper thorax, below the collarbone) or femoral vein (a large vein in the thigh) catheter; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the record was accurate and complete when staff did not document a change of condition for one resident (Resident #58) when the resident's condition declined and facility staff sent the resident to the hospital where the resident was diagnosed with osteomyelitis (a bone infection) and cellulitis (an infection of the tissue) out of a selected sample of 21 residents were selected for review in a facility with a census of 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-admitted to the facility from the hospital on 4/24/19; -Moderate cognitive impairment; [...]