Rock Point Nursing Center

Inspectors wroteBased on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 71. The facility did not provide a policy regarding dietary. 1. Observation on 03/17/26 at 9:50 A.M., 03/18/26 at 10:23 A.M., and 03/19/26 at 6:16 P.M., of the kitchen showed: - One compartment and three compartment sinks with the hot side water temperature at 106 degrees Fahrenheit after one minute;- One large metal cookie sheet with dark brown carbon build-up in the corners and one small cookie sheet with carbon build-up in the corners; - The commercial gas range oven with excessive black grime build-up on all interior surfaces and on the floor beneath; [...]

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for three residents (Residents #80, #81 and #82) out of three sampled residents. The facility census was 71. Review of the facility's policy titled, Accounting and Records of Resident Funds, revised [DATE], showed:- The facility maintains accounting records of resident funds on deposit with the facility;- Individual accounting ledgers are maintained in accordance with generally accepted accounting principles;- Inquiries concerning a resident's personal funds account record are referred to the Administrator or to the business office. 1. Review of Resident #80's closed medical record showed:- The resident expired on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a homelike environment was provided for the residents residing on the Men's Locked Behavior Unit which affected 12 residents with the potential to affect all 15 residents on the unit. The facility also failed to provide a safe, clean, and comfortable homelike environment which could have the potential to affect all residents in the facility. The facility census was 71. [...]

Inspectors wroteBased on interview and record review, the failed to provide an appropriate diagnosis for the use of an antipsychotic (medication to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for two residents (Residents #9 and #16) and failed to attempt a gradual dose reduction (GDR) for an antipsychotic medication for one resident (Resident #16) out of five sampled residents. The facility census was 71. Review of the facility's policy Psychotropic Medication Use, revised 02/2025, showed:- An adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: a. an assessment of the resident's condition and therapeutic goals;b. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the amount a bed would be held for on the bed hold policy upon transfer to the hospital and failed to include the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsmen (advocate for the resident in nursing facilities), the mailing and email address for the agency for protection and advocacy for residents with intellectual disabilities, and the mailing, email address, and telephone number for the agency for protection and advocacy for residents with mental illness, within the transfer and discharge notices for four residents (Residents #1,#3, #24, and #41) out of four sampled residents. The facility census was 71. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for one resident (Resident #43) out of one sampled resident that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 73. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure placement of the urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was maintained for two residents (Residents #1and #5) out of two sampled residents. The facility census was 71. Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;- Be sure the catheter tubing and drainage bag are kept off the floor;- Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure training was provided, competence was assessed, and a physician's order was received for laryngectomy tube ([NAME] tube - a flexible silicone tube inserted into the stoma (neck opening) to maintain the airway opening) care to be completed independently, and the type and size of the [NAME] tube supplies, and to have all of the needed [NAME] tube supplies easily accessible for one resident (Resident #5) out of one sampled resident with a [NAME] tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for three residents (Residents #9, #13, and #16) out of three sampled residents. The facility census was 71. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control practices with hand hygiene and glove changes during wound care, and suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) care for one resident (Resident #1) and incontinent care for three residents (Residents #5, #38, and #75) out of three sampled residents. The facility failed to follow appropriate infection control practices when inserting a nasal cannula (a device used to deliver oxygen with two small tubes that fit into the nostrils) into the nares of one resident (Resident #38) after it lay on the floor. The facility census was 71. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 70. Review of the facility's policy titled, Homelike Environment, revised on February 2021, showed; - Residents are provided with a safe, clean, comfortable and homelike environment. The facility did not provide a maintenance log. 1. Observations on 01/08/25 at 8:22 A.M., and 01/09/25 at 8:52 A.M., of the dining room and the C unit showed: - A deep crack in the laminate flooring across the middle of the dining room, approximately 15 foot (ft) in length and approximately 1 inch (in) deep causing a shift in the walking surface; - Approximately 20 ft of missing baseboard trim along the entire dining room wall near the kitchen; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for three residents (Residents #16, #24, and #58) out of five sampled residents. The facility census was 70. Review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised July 2022, showed: - After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; - Residents who use psychotropic (medications that affect the mind, emotions, and behavior) medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with two errors made, resulting in an error rate of 7.14% for two residents (Residents #23 and #58) out of six sampled residents. The facility's census was 70. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The staff will have access to specific instructions from the manufacturer on all forms of insulin delivery systems; - The policy did not address insulin pen administration technique. Review of the Fiasp (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flextouch Pen (insulin in a pen-type device) instructions, revised, June 2023, showed: - Prime the pen by turning the dose knob to two units; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during tube feeding (liquid food delivered into the stomach by a tube) and incontinent care for one resident (Residents #21) out of four sampled residents. The facility census was 70. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - EBP is used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms; - Gloves and gown are applied prior to performing high contact resident care activity; - Examples of high-contact resident activities requiring EBP include: dressing, bathing, transferring, hygiene care, changing linens, changing briefs and assistance with toileting, device care or use for central line, feeding tube, tracheostomy/ventilator etc.) and wound care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADL's) when the facility did not provide showers at least weekly for five residents (Resident #8, #18, #23, #26, and #31) and at least twice weekly for one resident (Resident #38) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to shower frequency. Review of the shower list showed: - Resident #8 scheduled for a shower once a week on Tuesdays; - Resident #18 scheduled for a shower once a week on Wednesdays; - Resident #23 scheduled for a shower once a week on Fridays; - Resident #26 scheduled for a shower once a week on Tuesdays; - Resident #31 scheduled for a shower once a week on Wednesdays; - Resident #38 scheduled for a shower twice a week on Tuesdays and Fridays. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced the resident's dignity while eating for one resident (Resident #65) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Resident Rights and Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents will be treated with dignity and respect at all times; - Residents will be provided with a dignified dining experience. 1. Review of Resident #65's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility,dated 07/27/23, showed: - Cognition moderately impaired; - Requires limited assist of one staff for eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The deficient practice had the potential to affect all residents in the facility. The facility's census was 69. The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment. Observations of E hallway showed: - On 09/26/23 at 9:01 A.M., Room E3 with a 2 foot (ft.) x 4 inch (in.) puddle of liquid in the floor under the bedside table at the side of the bed; - On 09/26/23 at 12:17 P.M., Room E3 with a 2 ft. x 4 in. puddle of liquid in the floor under the bedside table at the side of the bed. The floor was sticky and the room had a strong urine odor. The bathroom floor with a 1/2 in. gap in tile in front of the toilet; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for the use of a trapeze (a device designed to assist residents in changing positions) for two residents (Resident #7 and #21) out of two sampled residents and failed to complete a resident assessment and safety evaluation for the use of a trapeze for one resident (Resident #21) out of two sampled residents. The facility census was 69. The facility did not provide a policy regarding trapeze use. 1. Review of Resident #7's Physician's Order Sheet (POS), dated September 2023, showed: - admission date of 11/18/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for two residents (Resident #8 and #21) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #8's Physicians Order Sheet (POS), dated August 2023, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and chronic respiratory failure whether with hypoxia (the absence of enough oxygen in tissues to sustain bodily functions) or hypercapnia (buildup of carbon dioxide in bloodstream); - An order for oxygen tubing (the tube delivering oxygen from the oxygen container to the person) to be changed, dated 04/12/23. The order did not address how often to change the oxygen tubing; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision of two residents residing on the secured behavioral unit during smoking which affected one resident (Resident #51) out of two sampled residents and one resident (Resident #20) outside of the sample. The facility census was 69. Review of the facility's policy titled, Smoking, dated 5/2021, showed: - Smoking is allowed in designated areas only; - All residents will be monitored by facility staff when smoking; - No resident may smoke unattended unless specifically care planned to do so. 1. Review of Resident #20's medical record showed: - Date of admission of 04/21/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly and gnat populations in the facility. This deficient practice had the potential to affect all residents. The facility census was 69. Review of the facility policy titled, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; - Windows are screened at all times; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. Observations of the B Hall showed: - On 09/28/23 at 10:51 A.M., two gnats flew around the toilet in room B7. [...]