Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 North Pointe Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and a history of wandering were not adequately supervised or protected by assistive devices. One resident exited the facility twice, once being found outside between vehicles, while another resident's Wander Guard system failed to lock the door as required. The facility's policies and care plans were not effectively implemented, resulting in lapses in supervision and safety.
A resident with severe cognitive impairment and multiple comorbidities was physically assaulted by another resident with a known history of aggressive behaviors, including prior incidents of combative actions toward staff and wandering into other residents' rooms. The assaulted resident sustained multiple bruises and lacerations, and was unable to recall the incident due to dementia. Staff and documentation confirmed that the aggressor's behaviors were ongoing and interventions were not sufficient to prevent the incident.
Three residents with cognitive and physical impairments did not receive necessary assistance with ADLs, resulting in two having long, unclean fingernails and one experiencing inadequate oral care. Staff were unaware of the residents' hygiene needs, and there was confusion about responsibilities for nail and oral care, despite facility policies requiring regular attention to these areas.
Two residents with physician orders for compression stockings to manage edema were repeatedly observed without the prescribed stockings, despite exhibiting swelling in their lower extremities. Staff interviews revealed confusion over responsibility for applying the stockings, lack of awareness of the orders, and absence of in-service training on compression stocking use. Care plans and documentation did not consistently address the need for compression stockings, and facility leadership confirmed that nurses were responsible for following these orders.
Two staff members failed to follow physician orders during medication administration, resulting in a medication error rate of 9.09%. One resident with anemia received double the prescribed dose of vitamin B12, while another resident with a g-tube did not receive the full dose of multiple medications due to residue left in cups and insufficient water flushes. Both staff admitted to not reviewing orders prior to administration, and facility policy on medication administration was not followed.
A resident with severe cognitive impairment and diagnoses of edema and high blood pressure did not have a care plan addressing edema or the use of compression stockings, despite these needs being identified in their assessment. Nursing management acknowledged missing the orders and failing to update the care plan, which did not meet the facility's policy for comprehensive, person-centered care planning.
A resident with significant medical and cognitive needs did not receive toenail trimming after readmission, despite expressing a desire for this care. Staff interviews revealed confusion about responsibility for foot care, and the resident was not referred to a podiatrist or included on the podiatry list, contrary to facility policy. The care plan did not address toenail trimming, and the resident's toenails remained untrimmed during the survey period.
A resident receiving IV fluids for fluid deficit and gastrostomy status was found to have IV tubing that was not labeled with the date, time, or nurse's initials, contrary to facility policy and professional standards. Nursing staff and facility leadership confirmed the omission during interviews, acknowledging that the tubing should have been labeled and that the failure was not identified during shift changes. The involved nurses were IV certified, and the facility's policy required such labeling.
A nurse left an Amoxicillin tablet unattended at a resident's bedside, contrary to facility policy requiring direct observation of medication administration. The resident, who had intact cognition and multiple medical diagnoses, did not take the medication immediately, and the nurse confirmed she left it while assisting another staff member.
A resident with a tracheostomy did not have required documentation on the MAR/TAR for weekly oxygen tubing changes as ordered by the physician. Staff failed to label the tubing with the date of last change, and interviews revealed that nurses did not consistently check or document tubing changes, despite prior training. The facility's policy did not address disposable respiratory tubing, and training records were incomplete or outdated.
A resident with hemiplegia and a history of stroke, who required substantial assistance with dressing, was spoken to in a rude and disrespectful manner by a CNA when she requested help changing clothes. The CNA told the resident to dress herself, contrary to her care plan and needs, and the interaction was captured on video. The resident felt disrespected but did not report fear or abuse.
A CNA in an LTC facility was found to have verbally abused a resident by speaking loudly and inappropriately within earshot of the resident, who was cognitively intact and dependent on staff for care. The incident was witnessed by the BOM and corroborated by another CNA. The resident reported feeling upset and embarrassed. The facility's investigation confirmed the unprofessional conduct, leading to the CNA's termination.
The facility failed to provide adequate pressure ulcer care for three residents, leading to worsening conditions and equipment mismanagement. A resident's Stage 3 ulcer worsened significantly due to inadequate monitoring, while another resident's low air loss mattress was unplugged, and a third resident's mattress settings were incorrect. These issues highlight systemic failures in pressure ulcer prevention and treatment protocols.
A facility failed to provide proper catheter care for three residents, lacking necessary catheter straps and privacy covers. One resident's drainage bag was found on the floor, contrary to care standards. Observations and interviews revealed non-compliance with catheter care protocols, impacting residents with urinary catheters and potentially contributing to their medical conditions.
The facility failed to maintain an effective infection control program during meal service, as a resident served drinks without proper sanitation and another resident moved around asking for dinner rolls, both actions not addressed by staff. Despite staff training on infection prevention, these practices were not enforced, and the administrator was unaware of the issues.
A resident with a history of suicidal ideation and multiple mental health diagnoses was admitted to an LTC facility without appropriate measures in place. The facility's baseline care plan failed to include her diagnosis, leading to an incident where she attempted to harm herself by ingesting hand sanitizer. Staff were unaware of her mental health history, contributing to the deficiency.
A resident with a history of suicidal ideation was admitted to an LTC facility without proper care planning, leading to an incident where she ingested hand sanitizer in an attempt to harm herself. The facility failed to recognize and address her mental health needs, resulting in a critical oversight in her care plan.
A facility failed to develop a baseline care plan for a resident with suicidal ideation, despite documented history and referral notes indicating such a diagnosis. The resident attempted self-harm by drinking hand sanitizer shortly after admission. Staff interviews revealed a communication breakdown, as the diagnosis was not effectively shared among the team, leading to a lack of appropriate interventions.
A facility failed to monitor a resident's weight weekly as prescribed by the dietitian, despite the resident's significant weight loss and severe cognitive impairment. The oversight was due to missed orders by the ADON and lack of follow-up by the DON, leading to a failure in maintaining the resident's nutritional status.
The facility failed to apply rolled wash cloths to a resident's hands for contracture management, despite the resident being in a persistent vegetative state with range of motion impairment. Staff interviews confirmed the usual practice of using rolled wash cloths, but they had not been applied, leading to a lapse in the resident's care plan.
The facility failed to remove expired medications and properly label insulin on the 200 Hall medication cart. An expired Vitamin B12 vial and an undated insulin vial were found, with staff acknowledging the oversight and the potential ineffectiveness of these medications.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard System
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for two residents identified as being at risk for elopement. One resident, with a history of vascular dementia, severe cognitive impairment, and repeated falls, was known to have confusion and wandering behaviors. Despite being previously identified as at increased risk for elopement through multiple risk assessments, this resident was not provided with a wandering/elopement alarm and was able to exit the facility on two occasions. On the first occasion, staff were able to redirect her immediately, but on the second occasion, she exited through an exterior door, was found outside between two vehicles on the ground, and was subsequently assisted back inside. The care plan for this resident included interventions such as monitoring for wandering, providing diversions, and staying with the resident if exit-seeking, but these measures were not sufficient to prevent the elopement event. Another resident, also with severe cognitive impairment and a history of dementia, was identified as being at risk for elopement and was supposed to be monitored with a Wander Guard bracelet. However, observations revealed that the Wander Guard system was not functioning properly, as the front door did not automatically lock when the resident approached, failing on two out of three attempts. This deficiency was confirmed by facility leadership. The resident's care plan and physician's orders required monitoring of the Wander Guard device for placement and function every shift, but the system's failure was not detected until it was directly tested during the survey. The facility's elopement prevention policy required that all exits accessible to residents have devices in place to alert staff of possible elopement attempts, such as Wander Guard systems or other alarms. Despite these policies and documented interventions, the facility did not ensure that the required systems were in place and functioning for residents at risk of elopement. This resulted in residents being able to exit the facility unsupervised or without the intended safeguards in place, as evidenced by the incidents involving both residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse when another resident physically assaulted her in a third resident's room. The assaulted resident had severe cognitive impairment, as indicated by a BIMS score of 03, and multiple diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia, anxiety disorder, and depression. On the day of the incident, she was found with multiple bruises and lacerations on her arms, hands, legs, and head, as documented in skin assessments and progress notes. She was unable to recall the incident due to her cognitive status. The resident who committed the assault had a history of behavioral issues, including physical aggression toward staff, wandering into other residents' rooms, and taking belongings. Progress notes and staff interviews documented several prior incidents where this resident was combative, hit or bit staff, and exposed himself in public areas. Despite these behaviors, he was not consistently monitored in a way that prevented him from accessing and harming other residents. On the day of the incident, staff found him in another resident's room holding a wheelchair footrest in the air, with the assaulted resident present and injured. Staff interviews and witness statements confirmed that the aggressive resident had a pattern of escalating behaviors and that staff had to frequently redirect him. The incident was discovered when a CNA noticed an unusual situation and intervened, finding the injured resident and the aggressor together. The facility's documentation and staff accounts indicate that the aggressive resident's behaviors were known and ongoing, but interventions in place were insufficient to prevent the assault, resulting in physical harm to another resident.
Failure to Provide Adequate ADL Assistance: Nail and Oral Care Deficiencies
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. Specifically, two residents with moderate cognitive impairment and extensive ADL needs were observed to have long, unclean fingernails with visible build-up underneath. Both residents required staff assistance for personal hygiene, and their care plans and Kardexes included instructions for regular nail care. Despite these documented needs, staff interviews revealed a lack of awareness regarding the condition of the residents' fingernails, and there was confusion among CNAs and nurses about their respective responsibilities for nail care. One resident expressed discomfort and a desire to have her nails cut, while staff acknowledged the nails were overdue for care. Another resident, also with moderate cognitive impairment and physical limitations, was found to have significant white build-up on her teeth, indicating a lack of regular oral care. The resident reported that her teeth had not been brushed for approximately two weeks and expressed a desire for more consistent oral hygiene. Staff interviews confirmed that oral care was not being performed as required, and there was inconsistency in staff understanding of the procedures for documenting and escalating refusals of care. The facility's policies required daily oral care and regular nail care, but these were not consistently implemented for the affected residents. The findings were based on direct observations, resident and staff interviews, and review of medical records and care plans. The deficiencies were not attributed to resident refusal, as documentation and interviews did not indicate consistent refusals or appropriate follow-up. The lack of proper ADL assistance placed the residents at risk for poor personal hygiene and related complications, as noted in the facility's own policies and staff statements.
Failure to Apply Compression Stockings as Ordered for Residents with Edema
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with physician orders and professional standards of practice. Both residents had physician orders for compression stockings to be applied in the morning and removed in the evening to address edema. Observations on multiple occasions revealed that neither resident was wearing compression stockings, and both exhibited signs of edema in their lower extremities. One resident, with severely impaired cognition, was observed without compression stockings and reported that staff only put regular socks on him. The other resident, who was cognitively intact, also reported that staff did not apply the compression stockings and only applied cream to his legs. Record reviews showed that the care plan for one resident did not address edema or the use of compression stockings, despite the physician's order. Interviews with staff revealed a lack of awareness and responsibility regarding the application of compression stockings. A CNA assigned to both residents was unaware of the order, believing it was the nurse's responsibility. The nurse assigned to the residents acknowledged the orders but cited distractions and lack of stockings in the residents' rooms as reasons for not applying them. The nurse also admitted to not having received in-service training on compression stockings. Further interviews with facility leadership confirmed that nurses were responsible for following physician orders and documenting the application or refusal of compression stockings. The ADON and interim DON both stated that failure to apply the stockings could worsen the residents' edema. It was also noted that there had been no in-service training on compression stockings for staff, and the facility's policy on antiembolism hose did not specifically address adherence to physician orders.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate as observed during medication administration by two staff members. Specifically, one medication aide administered an incorrect dose of vitamin B12 to a resident with anemia, giving a full 1000 mcg tablet instead of the ordered 0.5 tablet (500 mcg). The aide admitted to not reviewing the physician's order prior to administration and was unaware of the correct dosage, leading to the resident not receiving the intended therapy. Another incident involved a nurse administering medications via gastrostomy tube to a newly admitted resident with a history of stroke and dysphagia. The nurse failed to ensure all crushed medication was delivered, leaving residue in the medication cups, and did not flush the tube with the prescribed amount of water before and after administration. The nurse acknowledged not reviewing the physician's orders and was aware that not all medication was administered, which could result in the resident not receiving the full therapeutic dose. Interviews with facility leadership, including the ADON and Interim DON, confirmed that staff are expected to review physician orders and ensure complete administration of medications, especially for residents with g-tubes. The facility's policies also require verification that medication cups are clear of remnants and that the correct flushing protocol is followed. However, these protocols were not adhered to during the observed medication passes, contributing to the elevated medication error rate.
Failure to Develop Comprehensive Care Plan for Edema and Compression Stockings
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with edema and an order for compression stockings. Record review showed that the resident, an elderly male with severe cognitive impairment and diagnoses including edema and high blood pressure, did not have his edema or the use of compression stockings addressed in his care plan, despite these needs being identified in his assessment. The care plan dated after the assessment did not include interventions or measurable objectives related to these conditions. Interviews with the ADON and the Interim DON confirmed that it was the responsibility of nursing management to update care plans when new orders were received. The ADON acknowledged missing the orders and not updating the care plan, which could result in not taking appropriate measures to address the resident's edema. The Interim DON also recognized the omission but did not perceive a risk as long as nurses followed the doctor's orders. The facility's policy requires a person-centered care plan to address all medical, physical, mental, and psychosocial needs, which was not followed in this case.
Failure to Provide Appropriate Foot Care and Toenail Trimming
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, chronic kidney disease, seizure disorder, and moderate cognitive impairment, did not receive appropriate foot care, specifically toenail trimming, after readmission to the facility. The resident required partial to moderate assistance with activities of daily living and expressed that no one had offered to trim her toenails since her readmission. Observations confirmed that her toenails were approximately 1/4 inch long, clean, thin, and in need of trimming, but she did not report pain. The resident's care plan addressed assistance with personal hygiene and oral care but did not specifically mention toenail trimming. There was no physician's order or referral to a podiatrist for foot care. Interviews with staff revealed inconsistent understanding of responsibilities regarding toenail care, with some staff indicating it was the responsibility of CNAs for non-diabetic residents and others stating it was the nurse's responsibility. Staff also described procedures for referring residents to podiatry, particularly for those with diabetes or thick toenails, but these procedures were not followed for this resident. The facility's foot care policy emphasized daily assessment and care of feet, with podiatrist involvement if required for toenail trimming. Despite this, the resident was not placed on the podiatry list, and no referral was made. Multiple staff interviews confirmed that the resident's toenails remained untrimmed, and the lack of action was attributed to unclear delegation and failure to follow established protocols for foot care and podiatry referral.
Failure to Label IV Tubing for Resident Receiving Parenteral Fluids
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) fluids did not have their IV tubing labeled with the date, time, and nurse's initials, as required by facility policy and professional standards. The resident, a female recently admitted with a history of cerebral infarction and gastrostomy status, was observed with a PICC line and IV fluids in place. During multiple observations, surveyors noted that the IV tubing lacked proper labeling, and this was confirmed by interviews with nursing staff and facility leadership. The nurses involved acknowledged awareness of the requirement to label IV tubing and admitted to missing this step, with one nurse stating she forgot and another stating she failed to check the tubing when taking over the shift. Facility policy required IV bags and tubing to be labeled with the date and nurse's initials when placed into use. Both the ADON and Interim DON confirmed their expectation that staff follow this policy and check equipment status at shift change. The failure to label the IV tubing was observed by both nursing staff and facility administration, and it was acknowledged that this omission could lead to infection. Training records indicated that the involved nurses were IV certified, and the facility's policy on intravenous fluid management was reviewed, which reiterated the labeling requirement.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a nurse left an Amoxicillin tablet unattended at a resident's bedside. The resident, a male with diagnoses including unspecified dementia, depression, essential hypertension, and acute respiratory failure with hypoxia, was found with a clear cup containing the medication on his bedside table. The resident reported that the nurse had dropped off the medication 15-20 minutes prior, and he had not yet taken it because he fell asleep. The nurse later confirmed she had provided the medication and left it at the bedside while she assisted another staff member, intending to return to the room. Facility policy requires that all medications be administered by licensed personnel and that the same person must pour, administer, and chart the medication. The Assistant Director of Nursing (ADON) stated that nurses are expected to observe residents taking their medications before leaving the room. The failure to follow these procedures resulted in the medication being left unsupervised at the resident's bedside.
Failure to Document and Label Respiratory Tubing Changes for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving respiratory care, specifically by not documenting the change of oxygen tubing as ordered by the physician. The resident, a female recently admitted with diagnoses including cerebral infarction and tracheostomy status, had physician orders requiring all disposable respiratory tubing and equipment to be changed weekly on Sundays. However, review of the medication administration record revealed no documentation indicating when the tubing was last changed. Observations showed the resident was receiving continuous oxygen therapy, but the tubing was not labeled with the date of last change. Interviews with the respiratory therapist, nursing staff, and administration confirmed that the tubing should have been labeled and changed according to the physician's order, but this was not done. Staff admitted to forgetting to label the tubing and not checking for labeling during their shifts, despite having received training on tracheostomy care. Further review indicated that the facility's policy on tracheostomy care did not address procedures for disposable respiratory tubing. Multiple staff members, including the ADON and interim DON, acknowledged the expectation to follow physician orders and label tubing, but there was a lack of documentation and oversight to ensure compliance. Training records were either not provided or outdated, and the failure to document and label the tubing was recognized by staff as a lapse in care.
Failure to Treat Resident with Dignity and Respect During Dressing Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during an interaction related to dressing assistance. The resident, who had a history of hemiplegia, diabetes mellitus, and stroke, was cognitively intact and required dependent or substantial assistance with dressing due to her physical limitations. On the day of the incident, the resident requested help from the CNA to change into pajama pants and a top before lunch. The CNA responded in a rude and disrespectful manner, telling the resident twice to put the pajama pants on herself, despite the resident's documented need for assistance. The resident reported feeling disrespected by the CNA's tone and behavior, although she denied experiencing fear, abuse, or physical harm. The incident was captured on video by the resident's daughter, which showed the CNA speaking unprofessionally and loudly to the resident. The facility's investigation confirmed that the CNA did not act professionally during the interaction. The resident expressed that she did not want the CNA to provide further care to her following the incident. Interviews with facility staff and review of the resident's care plan confirmed that the resident required two-person assistance for dressing and that care should be provided according to the resident's comfort and needs. The CNA's actions were inconsistent with the resident's care plan and the facility's policies on abuse, neglect, and resident rights. The event was identified as a failure to provide care in a manner that promoted the resident's dignity and quality of life.
Verbal Abuse Incident by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA A. The incident involved CNA A speaking in a verbally abusive manner about a resident, who was cognitively intact and dependent on staff for most activities of daily living due to conditions such as stroke, diabetes, and obesity. The resident's care plan included interventions for her left-sided paralysis and incontinence. The incident occurred when CNA A, frustrated with the resident's resistance during care, loudly expressed her anger in the hallway, within earshot of the resident, using inappropriate language. The incident was witnessed by the Business Office Manager (BOM), who heard CNA A's loud and inappropriate remarks from her office. The BOM confronted CNA A, advising her that such behavior was unacceptable and instructed her to seek assistance from another CNA. The BOM reported the incident to the Director of Nursing (DON) and the Administrator. Another CNA, identified as CNA B, corroborated the incident, noting that CNA A was agitated and loud but did not directly address the resident in an abusive manner. However, the resident overheard the remarks and reported feeling upset and embarrassed by the situation. The facility's investigation included reviewing video footage provided by the resident's family, which confirmed CNA A's unprofessional conduct. The Administrator suspended CNA A pending the investigation and later terminated her employment after substantiating the allegations of verbal abuse. The facility's policy on abuse and neglect clearly prohibits any form of abuse, including verbal abuse, within the hearing distance of residents.
Deficiencies in Pressure Ulcer Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment and care. Resident #1, a female with a history of cerebral infarction, diabetes, and vascular dementia, had a Stage 3 pressure ulcer on her coccyx that worsened significantly over a short period. Despite having a care plan in place, the wound increased in size from 5 cm x 1.5 cm x 0.1 cm to 12 cm x 10 cm x 0.1 cm within a week, indicating a lack of effective monitoring and intervention. The wound care nurse noted the wound's deterioration upon returning to work after a brief absence, suggesting that the resident's care was not adequately managed in her absence. Resident #6, a male with diabetes and a Stage 4 pressure ulcer, was found to have his low air loss mattress pump unplugged, rendering the mattress ineffective. This oversight was discovered during an observation, and the resident confirmed that the mattress had been non-functional for an unspecified duration. The nurse responsible for the resident's care was unaware of the issue, indicating a failure in ensuring the proper functioning of equipment critical to the resident's pressure ulcer management. Resident #7, a female with arthritis and Alzheimer's disease, was observed with incorrect settings on her low air loss mattress pump. The nurse could not articulate the appropriate settings, and the maintenance staff was reportedly responsible for setting up the equipment. This lack of knowledge and oversight in equipment management placed the resident at risk of developing pressure ulcers, as the mattress was not set according to the resident's needs. These deficiencies highlight a systemic issue in the facility's management of pressure ulcer prevention and treatment protocols.
Deficiencies in Catheter Care and Privacy Measures
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, as observed in three residents. These residents did not have catheter straps in place to prevent pulling or tugging, and their catheter drainage bags lacked privacy covers. Additionally, one resident's drainage bag was found resting on the floor, which is against standard care practices. These deficiencies were noted during observations and interviews conducted on a specific date. Resident #6, a male with a history of chronic kidney disease and severe sepsis secondary to a urinary tract infection, had a suprapubic catheter. Despite care plan interventions requiring a catheter strap and privacy cover, these were not in place during the observation. The resident had recently completed antibiotic treatment for a UTI, and although he denied discomfort, the lack of proper catheter management could have contributed to his condition. Resident #8, who had an indwelling urinary catheter to promote wound healing, was observed without a catheter strap, and his drainage bag was on the floor. Resident #9, with a history of paraplegia and neuromuscular bladder dysfunction, also lacked a catheter strap and privacy cover. Interviews with staff revealed a lack of adherence to catheter care protocols, as they were unable to explain the absence of necessary equipment and privacy measures. The facility's Director of Nursing acknowledged the oversight but was uncertain about the training provided to staff regarding catheter care.
Inadequate Infection Control During Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several incidents involving residents and staff in the dining room. During lunch service, a resident was observed serving lemonade and coffee to other residents without proper hand sanitation, which was not addressed by the staff present, including an LVN, MA, and the Activity Director. This resident, who had a history of stroke, diabetes, and moderate cognitive impairment, was not included in the care plan for assisting in the dining room, yet continued to serve drinks despite being told not to by staff. Additionally, another resident was observed moving around the dining room asking other residents for their dinner rolls, which was not discouraged by the LVN responsible for monitoring the dining room. This resident had a history of Alzheimer's disease and other medical conditions, and there was no indication that staff had informed him of the potential risks of his actions. Interviews with staff and residents revealed that the resident serving drinks was known to become confrontational when told not to assist, and the staff had not effectively prevented him from doing so. The facility's infection control training records showed that staff had been trained on hand hygiene and infection prevention, yet these practices were not enforced in the dining room. The facility's policies required training for individuals assisting with meal service, but it was unclear if the resident serving drinks had received such training. The administrator was unaware of the resident's actions and confirmed that the issue had not been addressed in the care plan, indicating a lack of oversight and communication within the facility.
Neglect of Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a documented diagnosis of suicidal ideation was free from neglect. The resident, a female with multiple mental health diagnoses including schizoaffective disorder, major depressive disorder, and suicidal ideation, was admitted to the facility without appropriate measures in place to address her condition. On the day of the incident, the resident reported drinking hand sanitizer in an attempt to harm herself, which was not anticipated or prevented by the facility's care plan. The resident had a history of attention-seeking behaviors and had previously attempted to harm herself by ingesting hazardous substances. Despite this, the facility's baseline care plan did not include her diagnosis of suicidal ideation, nor did it implement interventions to monitor and address her mental health needs. Staff interviews revealed that the resident frequently sought attention and expressed feelings of being unloved, which were not adequately addressed by the facility. The incident occurred when the resident approached staff with a small bottle of hand sanitizer, claiming she had ingested it to kill herself. The staff responded by providing one-on-one attention and contacting emergency services, but the lack of prior intervention and monitoring placed the resident at risk. The facility's failure to recognize and address the resident's suicidal ideation upon admission contributed to the deficiency, as staff were unaware of her mental health history and did not implement necessary precautions.
Failure to Implement Policies for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prevent the neglect of a resident diagnosed with suicidal ideation. Upon admission, the resident's diagnosis of suicidal ideation was not included in the baseline care plan, and no measures were put in place to address this critical aspect of her care. The resident, who had a history of suicidal attempts and ideations, was admitted without the necessary precautions, leading to an incident where she ingested hand sanitizer in an attempt to harm herself. The resident, a female with multiple mental health diagnoses including schizoaffective disorder, major depressive disorder, and suicidal ideation, was admitted to the facility without proper acknowledgment of her mental health needs. Despite the presence of a diagnosis of suicidal ideation on her face sheet, the facility staff, including the Administrator, DON, and ADON, failed to recognize and address this in her care plan. This oversight resulted in the resident being able to access and ingest hand sanitizer, which she reported doing with the intent to kill herself. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's suicidal ideation. The MDS Nurse, who created the resident's face sheet, assumed that others were aware of her diagnosis, leading to a critical gap in care planning. The resident's guardian and social worker were also unaware of the resident's suicidal ideation, which further highlights the communication breakdown within the facility. This deficiency placed the resident at significant risk and demonstrated a failure to protect her from neglect.
Failure to Implement Baseline Care Plan for Suicidal Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident with a documented diagnosis of suicidal ideation. Upon admission, the resident's diagnosis of suicidal ideation was not included in the baseline care plan, which is intended to provide effective and person-centered care. This oversight occurred despite the resident's history of suicidal attempts and ideations, as documented in referral notes from a previous facility and hospital records. The resident, a female with multiple mental health diagnoses including schizoaffective disorder and major depressive disorder, expressed suicidal ideation shortly after admission. On one occasion, she reported drinking hand sanitizer in an attempt to harm herself. The staff responded by providing one-on-one attention and contacting emergency services, but the lack of a comprehensive baseline care plan meant that appropriate interventions were not in place to address her suicidal ideation from the outset. Interviews with facility staff revealed that the diagnosis of suicidal ideation was not communicated effectively among the team. The MDS Nurse had included the diagnosis in the resident's face sheet but assumed others were aware. Key staff members, including the RN responsible for the baseline care plan, were unaware of the diagnosis, leading to a failure to implement necessary precautions. This communication breakdown contributed to the facility's inability to meet the resident's immediate needs upon admission.
Failure to Monitor Resident's Weight as Prescribed
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, specifically by not ensuring that the resident consistently received weekly weights as prescribed by the dietitian. The resident, an elderly female with severe cognitive impairment and significant weight loss, was supposed to be monitored weekly for weight changes. However, the facility did not follow through with this order, which was crucial given the resident's history of weight loss and her dietary needs, including a mechanical soft texture diet and nutritional supplements. The deficiency was identified through a combination of record reviews, observations, and interviews. The resident's weight had significantly decreased over a short period, and despite the dietitian's recommendation for weekly weights, this was not carried out. The Assistant Director of Nursing (ADON) admitted to missing the order for weekly weights, and the Director of Nursing (DON) acknowledged that it was her responsibility to ensure the orders were followed, but she was on leave during the critical period. Interviews with staff and family members revealed that while the resident was receiving her nutritional supplements and assistance with feeding, the critical component of weekly weight monitoring was neglected. This oversight was only discovered when the dietitian reviewed the resident's case again and found that the weekly weights had not been recorded. The facility's policy on resident weight monitoring was not adhered to, leading to a failure in maintaining the resident's nutritional status as required.
Failure to Apply Contracture Management Devices
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Specifically, the facility did not apply rolled wash cloths to the resident's hands for contracture management. This deficiency was observed in a resident who was in a persistent vegetative state with range of motion impairment in both upper and lower extremities. The resident was totally dependent on staff for all activities of daily living (ADLs) and had a care plan that included the use of rolled wash cloths to manage hand contractures. During observations, it was noted that the resident's hands were contracted and no devices were in place. Interviews with staff, including a CNA, LVN, and the Director of Rehabilitation, confirmed that the resident usually had rolled wash cloths in her hands, but they had not been applied. The Director of Rehabilitation acknowledged the need for hand rolls to prevent the resident's fingernails from pushing into her skin due to the contractures. The ADON also confirmed that residents with hand contractures should have a device in place to prevent worsening of the condition and avoid skin breakdown. The failure to apply the rolled wash cloths was not noticed by the staff, leading to a lapse in the resident's contracture management.
Failure to Remove Expired Medications and Label Insulin Properly
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and that expired medications were removed from the 200 Hall medication cart. Specifically, a Vitamin B12 vial with an expiry date of 9/2023 was found on the cart, and an insulin vial of Humalog Subcutaneous Solution 100 unit/ml was opened and partially used without an open date. These deficiencies were identified during an observation of the nurse's medication cart used for the Hall 200 with LVN A. LVN A acknowledged that it was the responsibility of all nurses to check the carts for expired medications and open dates on insulins, but she had failed to notice the expired Vitamin B12 vial and the undated insulin vial during her check. She stated that expired medications might not be effective if administered, and undated insulin could lead to uncontrolled blood sugar levels in residents due to its 28-day efficacy period after opening. The Director of Nursing (DON) confirmed that her expectation was for nurses to check for open dates and expired medications in their carts. She reiterated that undated insulin would make it difficult to determine its expiration, potentially leading to less effective blood sugar control in residents. The DON also stated that expired medications, if administered, would not be effective. The facility's current policy on Types and Actions of Insulin, dated 2003, did not address opening dates, and no policy addressing expired medications was provided upon request. The DON could not recall whether she had conducted training with staff on this matter, and no in-service record was presented.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Valley Healthcare And Rehabilitation Center | 0.9 mi | ★★★★★ | 4 | 1 |
| Avir At North Richland Hills | 2.3 mi | ★★★★★ | 5 | 0 |
| Glenview Wellness & Rehabilitation | 3.4 mi | ★★★★★ | 18 | 0 |
| Heritage House At Keller Rehab & Nursing | 3.4 mi | ★★★★★ | 7 | 1 |
| Avir At Richland Hills | 3.9 mi | ★★★★★ | 6 | 0 |
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