Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with diabetes and pressure ulcers did not consistently receive ordered wound dressing changes, as evidenced by multiple incomplete entries on the TAR over several months. The DON confirmed missing documentation for both completed and refused treatments, with no corresponding progress notes explaining refusals.
A resident with dementia, chronic pain, and a history of left hip dislocations did not receive care as outlined in the care plan, including use of a knee immobilizer, proper wheelchair leg support, and assistance with transfers and meals. Staff failed to follow updated care plan interventions, did not use required safety equipment during transfers, and were unaware of key care instructions, resulting in the resident being left unsupervised and improperly positioned.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident with a history of pneumothorax and mild intellectual disabilities was not permitted to return to the facility after a hospital stay, despite being medically cleared and expressing a desire to return. Facility staff cited behavioral concerns and placed the resident on a 'do not admit' list without proper documentation or following required discharge procedures. Communication and documentation failures, including an incomplete bed hold form and lack of clear authorization, contributed to the resident's inability to return.
The facility failed to meet the needs of two residents, one of whom waited over an hour and a half for assistance to move from a wheelchair to bed, and another who did not receive lunch for two days due to a computer issue. These incidents highlight deficiencies in responding to residents' needs and ensuring meal service.
A resident with a history of dementia and recent antibiotic use reported loose stools for several days, raising concerns of a C. diff infection. The facility failed to promptly notify the NP or implement contact precautions. Observations showed a lack of appropriate signage and delayed communication among staff, leading to inadequate infection control measures.
A resident with cognitive impairments and a history of psychiatric issues eloped from a facility after expressing a desire to leave. Despite these statements, the resident was not considered at risk for elopement and was not equipped with a wanderguard. The resident exited the facility, triggering the door alarm, but staff did not respond promptly. A CNA eventually retrieved the resident from a nearby highway. The facility's policy emphasizes supervision and timely alarm response, which were not adequately followed in this incident.
The facility failed to maintain proper dish machine sanitization and clean food contact surfaces, increasing the risk of foodborne illness for all residents. The dish machine's chlorine sanitizer concentration was undetectable, and the hot water rinse temperature was inconsistent. Additionally, chafing pans were stored wet, and mechanical scoops were found soiled with food debris.
The facility failed to follow professional standards for medication administration for four residents, resulting in medication errors and administration outside of physician-ordered parameters. Blood pressure and heart rate assessments were either not conducted or falsified, and doses of medications were missed or inaccurately documented.
The facility failed to ensure call lights were within reach and answered promptly, and that resident needs were met in a timely manner for three residents. One resident, a quadriplegic, was found without his call light, leading to pain and anxiety. Another resident reported not being able to get out of bed due to staffing issues, and a third resident experienced significant delays in toileting assistance, causing discomfort.
A resident with dementia and hemiplegia experienced an unwitnessed fall resulting in a head injury. Despite instructions to initiate neurological checks, these were discontinued after the resident returned from the hospital with negative CT results. Miscommunication and lack of a clear policy led to inadequate monitoring, potentially compromising the resident's health and safety.
The facility failed to properly secure medications for a resident with cognitive impairment. Observations revealed that prescription Triad cream was within reach of the resident, who had not been evaluated for self-administration. Staff confirmed that treatment creams should not be stored in resident rooms without an assessment deeming the resident safe to self-administer.
The facility failed to assess and monitor an infection for a resident with a history of recurrent urinary tract infections. Despite a positive UTI being identified, the facility did not follow its Antibiotic Stewardship Program protocols, resulting in the resident going unassessed and unmonitored, with the potential for further decline and complications.
The facility failed to provide an adequate Activities Program for seven residents, resulting in boredom and feelings of anger, frustration, and depression. Due to staffing cuts, activities were reduced to two per day during the week, with no activities on the weekends, and one-on-one activities for bed-bound residents ceased. This led to increased resident behaviors, sadness, and a decline in their overall quality of life.
The facility failed to notify residents and their families about the elimination of scheduled activities and did not obtain informed consent from a resident's legal guardian before starting a new psychotropic medication. This led to a significant alteration in the care and treatment plan for the residents, particularly affecting a resident with a history of major depressive disorder and intellectual disabilities.
The facility did not review or update its Facility Assessment before eliminating the Activity Budget, Activity Assistants, and other key positions, leading to a significant reduction in meaningful activities for residents. The Nursing Home Administrator confirmed that residents and families were not informed in advance, and the Facility Assessment was not updated to reflect these changes.
The facility failed to meet the shower and hygiene needs for four residents, resulting in frustration and an unkempt appearance. One resident did not receive a shower during his stay, another had only two showers in three weeks, and two others had no documentation of showers despite their conditions requiring assistance.
The facility failed to ensure that residents received their mail on Saturdays due to staffing cuts, affecting their right to access communication. Interviews with residents and staff confirmed the issue, and a review of policies highlighted the lack of a concrete plan for weekend mail delivery.
A resident with multiple diagnoses, including severe protein-calorie malnutrition, experienced significant weight fluctuations due to the facility's use of an uncalibrated home style scale after the facility's scale broke. This led to confusion about the resident's true weight and medical needs.
The facility failed to adequately assess and monitor a resident's tube feeding placement and intake, leading to confusion about the amount of tube feeding received. The resident, with multiple diagnoses including severe protein-calorie malnutrition and dysphagia, had her feeding tube disconnected and reported requesting a new device. The facility did not document tube feeding intake or placement assessments, resulting in a significant weight loss for the resident.
The facility failed to implement behavioral interventions before administering psychotropic drugs and did not limit PRN psychotropic drugs to 14 days for a resident with multiple diagnoses. The resident exhibited behavioral symptoms, but non-pharmacological interventions were not consistently attempted. Additionally, the facility's budget cuts led to a reduction in meaningful activities, contributing to the resident's distress.
Failure to Complete and Document Ordered Wound Treatments
Penalty
Summary
The facility failed to implement ordered wound treatments for one resident who was admitted with diagnoses including diabetes, a pressure ulcer, and muscle weakness. The resident was assessed as cognitively intact, with a perfect score on the Brief Interview for Mental Status (BIMS). The resident reported that staff did not always complete her dressing changes as ordered. Review of the Treatment Administration Record (TAR) revealed multiple instances over several months where wound dressings for the resident's right lower anterior leg, right buttock, and left shin were not marked as completed by nursing staff. The Director of Nursing confirmed that there was no documentation indicating that the dressings were completed or refused on several specific dates. Additionally, refused dressing changes were not accompanied by corresponding progress notes explaining the circumstances, as required.
Failure to Implement Care Plan Interventions for Safe Transfers and Positioning
Penalty
Summary
The facility failed to implement care plan interventions and standards of care for safety with transfers, positioning, and wheelchair equipment for a resident with significant musculoskeletal and cognitive impairments. The resident, a male with dementia, chronic pain syndrome, a left hip prosthesis, intracranial injury, and muscle weakness, had a history of left hip dislocations and was care planned to have a knee immobilizer in place at all times, use left posterior hip precautions, and receive limited assist with sit-to-stand transfers to a wheelchair. The care plan also specified that the resident should eat meals in the dining room due to fall risk and required cueing for eating. Observations revealed multiple failures to follow the care plan. The resident was found eating breakfast in bed without staff assistance, struggling to cut food, and not using the dining room as care planned. The resident's wheelchair did not have a proper leg rest to support his left leg, and the walker with wheelchair footrests was left at his bedside, contrary to care plan instructions. During a transfer, a CNA did not use a gait belt and was unaware of the updated care plan interventions, including the requirement for a sit-to-stand lift for transfers. The CNA also did not know the resident was supposed to eat in the dining room and had not read the care plan that day. Interviews with staff confirmed a lack of awareness and implementation of updated care plan interventions. The physical therapist was unaware that the resident did not have a proper leg rest for his wheelchair, and the unit manager could not explain why the resident was not in the dining room for meals or why the walker was left at the bedside. Documentation indicated that staff were supposed to be informed of care plan updates through a "stop and sign" process, but the CNA had not seen or signed it until prompted during the survey.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Resident Not Permitted to Return After Hospitalization Due to Behavioral Concerns and Documentation Failures
Penalty
Summary
A resident with a history of pneumothorax and mild intellectual disabilities was admitted to the facility and later transferred to a local hospital due to difficulty breathing and self-injurious behavior. While hospitalized, the facility's Social Services Manager requested a psychiatric evaluation for the resident before his return. The resident was deemed medically ready for discharge by the hospital, and the therapy department recommended sub-acute rehab. However, the facility declined to permit the resident's return, citing inappropriate behaviors and placing him on a 'do not admit' list, despite the absence of documentation supporting this decision in the medical record. Communication records between the hospital and facility admissions staff revealed that the facility informed the hospital that the resident was on a 'do not admit' list and that there was no bed available, although the hospital staff indicated the resident wished to return. The facility's Business Development Manager and Admission Director both referenced the resident's behaviors as the reason for refusal, but there was confusion and lack of clarity regarding who authorized the placement on the 'do not admit' list. The Nursing Home Administrator later reported that the decision was made without her knowledge and that the facility could have met the resident's needs. Documentation related to the resident's bed hold policy was incomplete and improperly executed, with missing signatures, dates, and unclear resident consent. The resident himself reported not understanding the bed hold refusal he signed. Facility policy required that residents be permitted to return after hospitalization unless a formal discharge process, including proper notification to the resident and the State Long-Term Care Ombudsman, was followed. In this case, there was no documentation of such a process, and the resident was not allowed to return to the next available bed.
Failure to Meet Residents' Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents, leading to deficiencies in care. Resident #114, an elderly female with diagnoses including muscle weakness and orthostatic hypotension, was observed with her call light on for an extended period. Despite her repeated requests for assistance to be moved from her wheelchair to her bed, she was left waiting for over an hour and a half before staff finally assisted her. This delay in response to her call light and her expressed need to lie down highlights a failure to meet her care needs promptly. Resident #112, another elderly female with diabetes mellitus and paraplegia, experienced a lapse in meal service. Despite being cognitively intact, as indicated by a perfect BIMS score, she did not receive her lunch tray for two consecutive days due to a computer issue that prevented her meal ticket from printing. This oversight was confirmed by a dietary aide, who acknowledged the problem. The failure to provide timely meals to Resident #112 demonstrates a lack of attention to her dietary needs and preferences.
Inadequate Infection Control for Resident with Suspected C. diff
Penalty
Summary
The facility failed to implement proper infection control practices for a resident who exhibited signs and symptoms of an infection. The resident, a male with a history of dementia, lack of coordination, weakness, and repeated falls, reported experiencing loose stools for several days. Despite the resident's complaints and the potential risk of Clostridium difficile (C. diff) infection due to antibiotic use, the staff did not promptly notify the Nurse Practitioner (NP) or take appropriate precautions. The NP was unaware of the resident's condition until informed during a routine check, at which point a verbal order was given to test for C. diff. The facility's failure to implement timely contact precautions and notify relevant staff members further exacerbated the situation. Observations revealed that the resident's room lacked appropriate signage for contact precautions, and staff were not informed of the need for such measures. The Unit Manager delayed notifying the Infection Control Nurse and did not ensure the collection of a stool sample promptly. Additionally, the signage used for contact precautions was incorrect, indicating the use of alcohol-based hand hygiene instead of soap and water, which is required for C. diff cases.
Elopement Incident Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident who was moderately cognitively impaired and had a history of dementia, bipolar disorder, and suicidal ideations. The resident, who had recently returned from a psychiatric hospital stay, expressed a desire to leave the facility and go home. Despite these statements, the resident was not considered at risk for elopement and was not equipped with a wanderguard device. On the night of the incident, the resident continued to express a desire to leave, and staff attempted to monitor her as much as possible. In the early morning hours, the resident managed to exit the facility without staff knowledge, triggering the front door alarm. A CNA observed the resident walking on a nearby road but did not initially recognize her as a resident. Upon entering the facility and hearing the alarm, the CNA informed an LPN, who confirmed the resident's identity. The LPN did not initiate a code search, believing it unnecessary since the resident's identity was known. The CNA then went outside to retrieve the resident, who was found standing on a state highway. The facility's policy on elopement and wandering residents emphasizes the need for adequate supervision and timely response to alarms. However, during the incident, staff were occupied with other duties and did not respond promptly to the door alarm. The LPN acknowledged that a wanderguard should have been used when the resident expressed a desire to leave, as its alarm is louder and more noticeable. The failure to implement appropriate interventions and respond effectively to the alarm led to the resident's elopement and placed her at risk of harm.
Failure to Maintain Dish Machine Sanitization and Clean Food Contact Surfaces
Penalty
Summary
The facility failed to maintain proper dish machine sanitization and clean food contact surfaces, leading to an increased risk of foodborne illness for all residents consuming food from the kitchen. During an inspection, it was observed that the dish machine's chlorine sanitizer concentration was undetectable, and the hot water rinse temperature was inconsistent at 143 degrees Fahrenheit. The Dietary Manager acknowledged the issue and stated that they would use the three-compartment sink for dishwashing until the dish machine could be serviced. However, even after a technician serviced the dish machine, the sanitizer concentration remained inconsistent, prompting frequent testing by the dietary staff. Additionally, four chafing pans were found stored wet in a manner that did not allow for proper air drying, and three mechanical scoops in the prep table drawer were observed to be wet and soiled with food debris. The Dietary Manager confirmed these findings and removed the items for re-washing. These observations indicate a failure to adhere to the 2017 FDA Food Code standards for equipment and utensil sanitization and storage, which require that food-contact surfaces be clean to sight and touch and stored in a self-draining position that allows air drying.
Medication Administration Failures
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in medication errors and medications being administered outside of the physician-ordered parameters. For Resident #38, there were multiple instances where blood pressure assessments were either not conducted or falsified before administering Sildenafil Citrate, which was to be held if the systolic blood pressure was less than 100. This led to the medication being administered without proper assessment or even when the blood pressure was outside the prescribed parameters. For Resident #68, Amiodarone HCl was administered despite the resident's heart rate and blood pressure being below the physician-ordered parameters on several occasions. Specifically, the medication was given when the heart rate was less than 60 and the systolic blood pressure was less than 90, contrary to the prescribed instructions. This indicates a failure to adhere to the required pre-administration assessments. Resident #1 and Resident #23 both experienced medication administration errors where doses of their prescribed medications were either missed or inaccurately documented. For Resident #1, a dose of Lacosamide was missed in the morning but documented as administered. Similarly, for Resident #23, a dose of Brivaracetam was not administered but was later documented as given, leading to discrepancies in the controlled substance count. These errors were confirmed by the Director of Nursing and highlight significant lapses in medication administration and documentation practices at the facility.
Failure to Ensure Call Lights Within Reach and Timely Assistance
Penalty
Summary
The facility failed to ensure that call lights were within reach and answered promptly, and that resident needs were met in a timely manner for three residents. Resident #18, a quadriplegic and ventilator-dependent individual, was found without his call light within reach, leading to feelings of helplessness and fear. He reported experiencing pain from being in the same position for an extended period and not being assisted to his wheelchair as requested. The call light was obscured by the privacy curtain, and staff confirmed it should have been within reach at all times. Additionally, there was no documentation to confirm that his requests to be up in his broda chair were honored, despite medical clearance for the same. Resident #18 also had a full-thickness friction skin injury on his buttocks, which was improving but still present. The lack of timely assistance and the inability to call for help exacerbated his discomfort and anxiety. The unit manager acknowledged the issue and mentioned reeducating the staff, but no corrective actions were documented before the survey exit. Resident #37, who is morbidly obese and dependent on a wheelchair, reported frustration over not being able to get out of bed when requested due to staffing issues. She mentioned that staff often told her they could not assist her because there were not enough staff available. This was corroborated by a CNA who stated that the number of CNAs on duty was insufficient to meet all residents' needs. The corporate consultant acknowledged the complaint and stated there should be enough staff, especially on weekdays, but the issue persisted. Resident #50, who has multiple sclerosis and requires substantial assistance with toileting and transfers, reported waiting up to 30 minutes for toileting assistance after pressing his call light. He recounted an incident where he had a bowel movement in his wheelchair and had to wait 30 minutes for assistance, causing him discomfort. He also mentioned another instance where he waited 30 to 40 minutes to be taken off a bedpan, which caused him pain. The delays in responding to his call light were consistent and caused significant discomfort.
Failure to Monitor Resident After Fall with Head Injury
Penalty
Summary
The facility failed to adequately monitor a resident after a fall with a head injury. Resident #27, who was admitted with diagnoses including dementia, cerebral infarction, and hemiplegia, experienced an unwitnessed fall resulting in a head injury. Despite the Post Fall Assessment form instructing staff to initiate neurological checks, these checks were discontinued after the resident returned from the hospital with negative CT results. The resident was on anticoagulant therapy, which increased the risk of complications from head injuries, yet no further neurological monitoring was conducted upon her return to the facility. Licensed Practical Nurse (LPN) J, who was on duty when the resident returned from the hospital, reported that she was informed by another nurse that neurological checks were unnecessary if the CT scan was normal. LPN J did not discuss the discontinuation of neurological checks with the Physician's Assistant (PA) C, who was supposed to evaluate the resident but did not have time. Registered Nurse (RN) D, who was not directly involved in the resident's care, stated that she would normally continue neurological checks after a head injury, even if the initial hospital tests were normal. The Director of Nursing (DON) confirmed that there was no facility policy or procedure directing staff on when to complete or discontinue neurological checks. The Corporate Consultant (CC) A reviewed the Post Fall Assessment form and acknowledged the need for staff education regarding neurological checks. The lack of a clear policy and procedure, combined with miscommunication among staff, led to the failure to adequately monitor Resident #27 after her fall, potentially compromising her health and safety. The facility's Fall Reduction Policy, which mandates assessment and completion of a Post-Fall Assessment, was not effectively implemented in this case.
Failure to Properly Secure Medications
Penalty
Summary
The facility failed to properly secure medications for Resident #435, who was moderately cognitively impaired with diagnoses including Parkinson's Disease and dementia. Observations on multiple dates revealed that prescription Triad cream was within reach of the resident on the bedside table and in the bedside drawer. The resident had not been evaluated for self-administration of medication, and the cream was required to be stored in the treatment cart. Interviews with staff confirmed that treatment creams should not be stored in resident rooms unless there was an assessment on file deeming the resident safe to self-administer. The Triad cream in Resident #435's room came from the hospital and should not have been there. This resulted in unsecured medication and the potential for cross-contamination.
Failure to Monitor and Assess Infection
Penalty
Summary
The facility failed to assess and monitor an infection for one resident who was reviewed for antibiotic use. The resident, who was cognitively intact and had a history of recurrent urinary tract infections, was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and high blood pressure. Despite a positive urinary tract infection being identified through laboratory testing, the facility did not follow its own Antibiotic Stewardship Program protocols. Specifically, the resident's symptoms and vital signs were not monitored twice daily as required, and there was no documentation of these assessments in the progress notes from the time the infection was suspected until the antibiotic treatment began. During an interview, the Infection Control Preventionist confirmed that the staff should have followed the policy to obtain a urinalysis with culture and sensitivity and to monitor the resident's vital signs and symptoms twice daily. However, the necessary doctor's order could not be located in the electronic medical record, and the required monitoring and documentation were not performed. This lack of adherence to the established protocols resulted in the resident going unassessed and unmonitored, with the potential for further decline and complications from the infection.
Inadequate Activities Program Due to Staffing Cuts
Penalty
Summary
The facility failed to provide an adequate Activities Program for seven residents, resulting in boredom and feelings of anger, frustration, and depression. The facility's policy on activities, which was last reviewed on an unspecified date, stated that it would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. However, due to staffing cuts, the activities program was significantly reduced, leading to negative impacts on the residents' well-being. One resident expressed that activities used to be available from morning until night, providing a social outlet and keeping them busy. However, with the reduction in activities, the resident felt bored, depressed, and angry. Another resident, who was described as a social butterfly, became very depressed and even attempted self-harm after the activities were reduced. The Activities Director confirmed that the department had lost five employees due to staffing cuts, leaving her as the only member of the team. As a result, activities were reduced to two per day during the week, with no activities on the weekends, and one-on-one activities for bed-bound residents ceased. Other residents also expressed their dissatisfaction with the reduced activities, stating that it made them feel unimportant and led to increased feelings of depression and boredom. Staff members, including a Registered Nurse and a Physical Therapist, observed an increase in resident behaviors and sadness since the cuts were made. The lack of activities and social interaction significantly impacted the residents' mental and emotional well-being, as they no longer had a routine or schedule to look forward to, leading to a decline in their overall quality of life.
Failure to Notify and Obtain Consent for Medication and Activity Changes
Penalty
Summary
The facility failed to notify residents, family members, and resident representatives in advance of the elimination of the majority of scheduled program activities. Additionally, the facility did not provide notification or obtain informed consent from the legal guardian of a resident before starting a new psychotropic medication, Depakote. This resulted in a significant alteration in the plan of care and treatment for all residents living at the facility, particularly affecting Resident #103, who had a history of major depressive disorder, intellectual disabilities, and other conditions. Resident #103 was cognitively intact and had a guardian in place to assist with financial and medical decisions. The resident's care plan emphasized the importance of consistent routines and participation in activities. However, the facility's decision to eliminate the activity budget and staff led to a noticeable decline in the resident's mental health. The resident's legal guardian was not informed of these changes until after they had occurred, and the resident began exhibiting increased behavioral issues, including anxiety and agitation. Furthermore, the facility started Resident #103 on Depakote without obtaining prior informed consent from the legal guardian. The medication was administered on the evening of April 2, 2024, and the guardian was only informed the following day. This action was against the facility's policy, which requires informed consent before starting new medications or making changes to the treatment plan. The failure to notify and obtain consent led to a significant alteration in the resident's care and treatment plan.
Failure to Update Facility Assessment and Notify Residents of Changes
Penalty
Summary
The facility failed to follow its Facility Assessment policy by not reviewing and revising the assessment with input from relevant department heads and resident groups before making substantial modifications. Specifically, the facility did not notify residents, families, or resident representatives in advance of the elimination of the Activity Budget, Activity Assistants, and other key positions, resulting in a significant reduction in meaningful activities for residents. The Facility Assessment had not been updated to reflect these changes since January 2024, despite the policy requiring updates whenever substantial modifications are planned or implemented. During an interview, the Nursing Home Administrator (NHA) confirmed that residents and families were not informed about the changes, and the Facility Assessment was not reviewed or updated accordingly. An emergency Resident Council meeting revealed that residents were very concerned about the elimination of activity staff and other positions. The NHA explained that the decision was not his and that he had tried to retain the staff. The Employee Roster provided to the surveyor showed only one employee remaining in the Recreation Department, indicating a significant reduction in staff and resources dedicated to resident activities.
Failure to Meet Shower and Hygiene Needs
Penalty
Summary
The facility failed to meet the shower and hygiene needs for four residents, resulting in frustration and an unkempt appearance. Resident 6, a male with multiple diagnoses including a fractured left femur and diabetes, did not receive a shower during his stay from 11/17/23 to 11/22/23. The Director of Nursing (DON) confirmed that there was no documentation of a shower being provided. Resident 8, admitted for surgical aftercare, had only two documented showers during a three-week stay, missing his scheduled weekly showers. A concern form from a family member highlighted that Resident 8 had not been showered or had his diaper changed for several days, which was corroborated by the DON and a Registered Nurse (RN). Resident 11, a female with severe medical conditions including acute pancreatitis and brain injury, had no documentation of a shower since her admission on 1/27/24. An observation on 2/5/24 revealed that her hair was greasy and uncombed, and she denied receiving any assistance with a shower. Resident 12, who required one-person assistance with showers, was observed with greasy and uncombed hair on 2/5/24. Her shower documentation showed that she missed a scheduled shower on 1/25/24 without any provided reason. The DON confirmed that Resident 12 should have received a shower on that date.
Failure to Ensure Weekend Mail Delivery
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, affecting their right to access communication. This issue was identified through interviews with three residents and staff members. Resident 7, the resident council president, expressed concern about the lack of weekend mail delivery due to staffing cuts. Resident 9 and Resident 17 also confirmed that they no longer received mail on Saturdays, with Resident 17 specifically mentioning the inconvenience of not receiving his newspaper on time. The Business Manager and Activities Director both acknowledged the problem, noting that the activities staff used to handle weekend mail delivery before being let go, and no concrete plan was in place to address the issue. A review of the facility's policy on resident rights revealed that it did not specify the requirement for mail delivery on Saturdays. However, the Medicaid Care and Coverage guidelines clearly state that residents have the right to receive mail the day it is delivered to the facility. The lack of a set plan for weekend mail delivery and the recent staffing cuts led to the deficiency, impacting the residents' ability to exercise their right to receive mail and access communication.
Inaccurate Weight Measurement
Penalty
Summary
The facility failed to accurately weigh a resident, leading to confusion about the resident's true weight and medical needs. The resident, a [AGE] year-old female with multiple diagnoses including severe protein-calorie malnutrition and dysphagia, expressed concern about her weight. Despite her concern, the facility used a home style scale, which cannot be calibrated for accuracy, to take her weight. The weights recorded showed significant fluctuations, with a notable weight loss of 12 pounds in 9 days. The resident and her family advocate were disappointed and requested to speak with the physician regarding the significant weight loss. Interviews with staff revealed that the home style scale was used after the facility's scale broke, and the staff could not recall when this occurred. The resident's weights were taken by different CNAs, and there was inconsistency in the method and location of weighing. The Registered Dietitian confirmed that the facility had been using the home style scale for an unknown period and emphasized the need for accurate scales. The facility's failure to use a reliable and calibrated scale led to inaccurate weight measurements, causing confusion about the resident's true weight and medical needs.
Failure to Monitor and Document Tube Feeding Placement and Intake
Penalty
Summary
The facility failed to adequately assess and monitor the tube feeding placement and intake for a resident, resulting in confusion about the amount of tube feeding received and the need for further intervention. The resident, a [AGE] year-old female with multiple diagnoses including traumatic brain injury, severe protein-calorie malnutrition, and dysphagia, had her feeding tube disconnected during observations. The resident reported requesting a new tube feeding device that secures the placement to reduce the risk of pullouts, and she had been sent to the emergency room due to concerns about the tube feeding placement. However, the facility did not have local services to provide the necessary care, and the resident was scheduled for follow-up care in the coming weeks. The resident's weights showed a significant decrease since admission, and there was no documentation of tube feeding intake or placement assessment in her electronic medical record. Interviews with facility staff confirmed that the resident's tube feeding intake was not being monitored, and there was no documentation of tube feeding placement assessments. The facility's dietitian acknowledged the lack of documentation and reported that an x-ray had been ordered to ensure proper placement, with plans to measure the feed once confirmed. The dietitian also educated the resident to keep the tube feeding running and implemented documentation of tube feeding intake every shift. Despite these actions, the deficiency was identified due to the initial failure to monitor and document the resident's tube feeding placement and intake properly.
Failure to Implement Behavioral Interventions and Adhere to PRN Medication Guidelines
Penalty
Summary
The facility failed to implement behavioral interventions before the initiation and administration of psychotropic drugs and ensure PRN psychotropic drugs are limited to 14 days for a resident. The resident, who had multiple diagnoses including major depressive disorder, generalized anxiety disorder, and chronic pain, exhibited behavioral symptoms such as verbal outbursts, fixation on a female staff member, and elopement risk. Despite these symptoms, the facility did not consistently attempt non-pharmacological interventions before administering psychotropic medications like Lorazepam and Depakote. The resident's care plan included interventions such as maintaining a consistent routine and providing activities to address behavioral symptoms. However, the facility did not document attempts to engage the resident in diversional activities or other non-pharmacological interventions before resorting to medication. For instance, the resident was given Lorazepam without documented non-pharmacological interventions, and the PRN order for Lorazepam did not have an end date or a documented rationale for extending it beyond 14 days. Additionally, the facility's budget for the Recreational Activity Department was eliminated, leading to a significant reduction in meaningful activities for residents. This lack of activities likely contributed to the resident's expressions of boredom and distress. The facility's failure to provide adequate non-pharmacological interventions and adhere to PRN medication guidelines resulted in the resident receiving unnecessary medications and experiencing ongoing distress.
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Illustrative
What surveyors actually found near you
We read the 113 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Greenville Hospital Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 6.1 mi | ★★★★★ | 9 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 15.5 mi | ★★★★★ | 12 | 0 |
| Optalis Health & Rehabilitation Of Ionia | 16.4 mi | ★★★★★ | 5 | 0 |
| The Laurels Of Kent | 17.7 mi | ★★★★★ | 12 | 0 |
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