Pointe Meadows Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility did not 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. Specifically, for 4 out of 49 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for a resident with a peripherally inserted central catheter (PICC) line and the glucose monitor was not disinfected between resident usage. Resident identifiers: 6, 29, 119, and 121.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality. Specifically, for 2 out of 49 sampled residents, medications were left unattended at a resident's bedside and a resident's tube feed was not labeled with the date and time. Resident identifiers: 5 and 128.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 49 sampled residents, a resident reported constipation with no bowel movement for five days and no effective treatment was provided. Resident identifier: 119.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and the drugs were stored under proper temperature controls. Specifically, for 2 out of 49 sampled residents, the medication cart contained an opened insulin vial that had expired and there were three unopened insulin auto injector pens that were stored in the medication cart instead of the refrigerator. Resident identifiers: 29 and 111.

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 2 out of 49 sampled resident's, laboratory results were not located in the medical record. Resident identifiers: 3 and 10.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was offered the pneumococcal vaccine. In addition, the resident's medical record did not include documentation that indicated the resident either received, refused, or the vaccine was medically contraindicated. Specifically, for 1 out of 5 sampled residents, a resident did not have documentation in the medical record stating either the pneumococcal immunization was offered, received, or refused. Resident identifier: 93.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in refrigerator and the walk-in freezer were open to air. Additionally, the dish machine was not reaching appropriate temperatures for sanitizing and staff were not using alternate methods of sanitizing dishware.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. Specifically, walls with large white patches and missing paint were observed.

Inspectors wroteBased on interview and record review, it was determined, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 34 sampled residents, the facility did not administer medication to provide for the physical, mental, and psychosocial needs of a terminally ill resident on hospice services. Resident identifier: 38.

Inspectors wroteBased on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, for 3 out of 34 sampled residents, medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifiers: 8, 43, and 58.

Inspectors wroteBased on observation and interview, it was determined, the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of medications were not labeled with open dates, medications were found expired and still available for use in two of the medication carts, and one medication refrigerator was found to have low temperatures not compatible with medication storage.

Inspectors wroteBased on observation and interview, it was determined, that the facility did not 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. Specifically, meal tray items were uncovered when delivered by staff throughout resident hallways and a staff member that was assisting residents with eating was cross contaminating. Findings Included: 1. On 11/13/23, lunch meal trays, which included, uncovered meal items were transported through resident hallway F. The meal cart was stationed near resident room F13. At 12:06 PM, a staff member was observed to carry a meal tray to resident room F17. The apple sauce and pudding were not covered. At 12:09 PM, a staff member was observed to carry a meal tray to resident room F15. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, for 3 out of 30 sampled residents, opened multi-dose vials of insulin were not labeled with open dates or expiration dates and were available for use. Resident Identifiers: 5, 44, and 60.

Inspectors wroteBased on observation and interview, it was determined the facility did not ensure to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the resident communal nourishment refrigerators included unlabeled, undated and expired items.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 5 out of 30 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' influenza and pneumococcal consent status or education of the benefits and potential risks associated with the immunizations. Resident identifiers: 3, 24, 38, 41, and 216.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease-2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 3 out of 30 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with the COVID-19 vaccination. Resident identifiers: 24, 38, and 216.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not treat residents with respect and dignity. Specifically, for 1 out of 30 sampled residents, a resident was without a urinal and was instructed by staff to urinate in his brief. Resident identifier: 47.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 30 sampled residents, the facility did not demonstrate implementation of care plan interventions related to a resident falls. Resident identifiers: 30 and 56.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, for 2 out of 30 sampled residents, the facility did not provide adequate supervision to prevent falls from occurring, and care plan interventions were not implemented. Resident identifiers: 30 and 56.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise. Specifically, for 1 out of 30 sampled residents, the facility did not implement a diet recommendation made by the Registered Dietician (RD) for 8 days after a resident had a significant weight change. Resident identifier:

Inspectors wroteBased on interview and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 30 sampled residents, a residents medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifiers: 47.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility provided residents with therapeutic diets as prescribed by the attending physician. Specifically, for 2 out of 30 sampled residents, the facility did not provide residents' with the cardiac diet as prescribed by their physician. Resident identifiers: 29 and 219.