Mission Point Nursing & Physical Rehabilitation Ce
For profit - Corporation
129 Beds
MISSION POINT HEALTHCARE SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#216 of 422 in MI
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mission Point Nursing & Physical Rehabilitation Center in Detroit has a Trust Grade of D, indicating below average quality and some significant concerns. It ranks #214 out of 422 facilities in Michigan, placing it in the bottom half statewide, and #32 out of 63 in Wayne County, suggesting that only a few local options are better. The facility is improving, having reduced its number of issues from 12 to 7 over the past year. Staffing is rated average with a turnover rate of 42%, slightly below the state average, but there are fewer registered nurses on duty than 76% of facilities in Michigan, which raises concerns about care coordination. While there have been no fines, a critical incident involved a failure to adhere to a resident's Do Not Resuscitate status, leading to unwanted CPR being performed, and another serious issue involved improper assistance during a mechanical lift transfer, resulting in a resident's rib fracture. Overall, while there are some strengths, such as the lack of fines and an improving trend, families should be aware of serious incidents and staffing challenges when considering this facility.
- Trust Score
- D
- In Michigan
- #216/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 49%
Review needed
12 → 7 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Michigan average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Michigan average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 42%
Near Michigan avg (46%)
Typical for the industry
Chain: MISSION POINT HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 27 deficiencies on record
1 life-threatening 1 actual harm
Mar 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R4) of two resident reviewed for...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R4) of two resident reviewed for catheters, resulting in the potential for feelings of diminished self-worth using the reasonable person concept.
Findings include:
On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4's right arm appeared contracted, with the arm toward their chest and fingers curled towards their palm. The drainage bag was exposed and revealed cloudy, amber colored urine. The catheter bag was not contained in a dignity bag and/or with a dignity covering. R4 was confused and was able to answer basic questions.
On 03/03/25 at 2:28 PM, R4 was observed in bed on their right side. The urinary catheter drainage bag remained in the same place without a dignity bag/cover in place.
A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of Schizophrenia, Contracture of Right Elbow, Muscle Wasting, Multiple Fractures and Muscle Weakness. A review of R4's Brief Interview for Mental Status (BIMS) revealed the resident was unable to complete the interview. A review of R4's Care Plan revealed the following:
Focus: I have indwelling catheter r/t (related to) wound management .Dated 1/7/2025 .Interventions/Tasks: Catheter: Position catheter and tubing below the level of the bladder covered for dignity.
On 03/04/25 at 12:55 PM, Nurse Manager E was informed that on 3/3/25 R4 did not have a privacy bag for their urinary drainage bag. Nurse Manager E said that it (the dignity cover) probably fell off but should have a cover.
On 03/05/25 at 11:49 AM, the Director of Nursing (DON) was asked regarding privacy bags and dignity in the facility. The DON stated that she expects that we have a privacy bag for all urinary drainage bags for dignity.
A review of the facility's policy Promoting/Maintaining Resident Dignity dated 2/2025 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Maintain resident's privacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the provision of hygiene and daily care for two ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the provision of hygiene and daily care for two residents, (R4 and R8) of two residents reviewed for assistance with Activities of Daily Living (ADL's), resulting in R4 not receiving timely fingernail care and R8 not receiving adequate facial hair care.
Findings include:
R4
On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4 was confused and was able to answer only basic questions. R4's right arm appeared contracted, with their arm toward their chest and fingers curled into a fist. R4's nail on their first finger of their right hand was long and jagged. R4's other nails on their right hand curled into a fist. When asked if they could open their right hand, R4 replied, No. Observation of the R4's left hand and fingernails revealed the fingernails were long and jagged.
A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of Schizophrenia, Contracture of Right Elbow, Muscle Wasting, Multiple Fractures, and Muscle Weakness. A review of R4's Brief Interview for Mental Status (BIMS) revealed the resident was unable to complete the interview. A review of R4's Care Plan revealed the following:
Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 10/19/2022 .Personal Hygiene: I am total assistance with personal hygiene care.
03/05/25 at 12:23 PM, the Director of Nursing (DON) was queried regarding R4's fingernails and said R4 refuses care at times, its care planned.
R8
An observation on 3/3/25 at 11:30 AM, R8 was sitting in a wheelchair, resident had a full, long, unkempt beard. R8 reported a preference to be clean shaven. It was further reported that staff does not ask or help him shave.
Review of electronic health record (EHR) revealed admission into the facility on 1/9/24 with a pertinent diagnosis of debility. According to the Minimum Data Set (MDS) dated [DATE], R8 required partial/moderate assistance with personal hygiene.
Review of Brief Interview for Mental Status (BIMS) dated 1/21/25, documented R8 scored 5 out of 15 (severely impaired cognition).
Review of ADL Self Care Performance care plan initiated on 12/2/23, documented, Personal Hygiene/Oral Care -requires 1 staff participation with personal hygiene and oral care. Further review of care plans revealed no specific interventions for shaving and no history of refusing care.
An observation of R8 on 3/4/25 at 9:27 AM, resident's beard remained full, long, and unkempt.
An interview was conducted on 3/4/25 at 9:33 AM with Unit Manager (UM) E, it was reported that staff should ask and assist R8 with shaving. If a resident does not want to be shaven, a progress note should be written to reflect the resident's choice. Review of R8's progress notes from February and March of 2025 revealed no refusals to be shaven.
Review of the facility policy Activities of Daily Living (ADLS) dated 2/25/24, documented the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician responded to pharmacy recommendations in a timely...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a physician responded to pharmacy recommendations in a timely manner for one resident (R52), out of five residents reviewed for unnecessary medications.
Findings include:
A review of the clinical record for R52 documented an admission date of 7/5/24 with diagnoses that included heart failure, Parkinson's Disease, psychotic disorder with hallucinations, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood. A Minimum Data Set, dated [DATE] documented severe cognitive impairment and administration of antipsychotic and antianxiety medications. Physician's current orders for R52 documented to administer Xanax tablet 0.25 mg by mouth every 12 hours as needed for anxiety with a start date of 2/25/2025.
Review of R52's pharmacy consultations identified irregularities on 8/7/24, 9/13/24, and 10/11/24 which all indicated, Recommend discontinuing PRN (as needed) use of Xanax for this Resident, OR reorder for a specific number of days, per the following federal guidelines: In accordance with State and Federal Guidelines, revised regulation 483.45(e) Psychotropic Drugs PRN, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he or she should document the rationale in the Resident's medical record and indicate the duration for the PRN order. There was no response to these repeated pharmacist's recommendations, signature or date from the physician until 11/11/24.
Review of R52's care plans documented the following:
- I have a history of trauma that can negatively affect my care and treatment. A survivor of 9/11. Signs/symptoms (anxiety/fear/anger/mood swings/nightmares/sleep changes/pain/withdrawal), revised on 1/22/25.
- I have the potential for mood difficulties and/or adjustment concerns related to anxiety and depression, dementia and decrease in appetite, initiated on 2/4/25.
On 3/5/25 at 1:34 PM, the Director of Nursing (DON) said the pharmacist conducts monthly medication reviews on the residents in the facility and will recommend a medication change if indicated. The DON added that the physician was responsible to respond to the recommendations. A review of R52's clinical record and pharmacist's recommendations was conducted with the DON. The DON could not provide documentation to support that R52's physician had reviewed and responded to the pharmacist's recommendations of 8/7/24, 9/13/24, and 10/11/24 prior to 11/11/24. The DON acknowledged that the response from R52's physician was not timely.
The facility policy titled, Medication Regimen Review, dated January 2024, was reviewed and documented in part the following:
- The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.
- The Medication Regimen Review (MRR) includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.
- Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.
On 3/5/25 at 3:30 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food items listed as always available were on ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food items listed as always available were on hand to ensure resident food preferences were honored for one resident (R6).
Findings include:
During an interview on 3/3/25 at 10:50 AM, R6 was observed awake and lying in his bed. When queried if he was getting enough food to eat, R6 indicated he was not. When queried if he was offered an alternative menu item, R6 indicated that the menu items were not always available. A sheet of paper titled, Always Available Menu was attached to the bulletin board in R6's room. When queried if these menu items were always available, R6 indicated no.
During an observation and interview on 3/3/25 at 11:30 AM with Dietary Manager (DM) G, the following items listed on the always available menu posted in R6's room were not in stock in the kitchen: sliced turkey lunch meat and cottage cheese. DM G acknowledged that always available menu items should always be available.
During an interview on 3/4/25 at 3:01 PM, DM G said they should have had sliced turkey available. DM G indicated that cottage cheese had been removed from the always available menu. DM G said the purpose of the always available menu was to offer residents alternate food choices.
During an interview on 3/5/15 at 11:19 AM, Certified Nurse Aide (CNA) J said R6 was able to communicate food items he wants to eat. CNA J confirmed that R6 had ordered food off the always available menu because occasionally he wanted something other than the main menu entree.
A review of the clinical record for R6 revealed an initial admission date of 3/22/12 and readmission date of 7/5/16. A Minimum Data Set assessment dated [DATE] documented intact cognition.
On 3/5/25 at 11:47 AM, the Nursing Home Administrator (NHA) stated the always available menu was in place to offer the residents a variety of foods to cover the broad spectrum of their preferences. The NHA added the items on the always available menu should always be available during the hours that the kitchen was opened.
On 3/5/25 at 3:30 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate ...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 84 residents in the facility.
Findings include:
On 3/5/25 at 11:13 AM review of the nurses' schedule for the months of July, August and September 2024 with staffing coordinator K, revealed there was no Registered Nurse (RN) coverage on the following dates:
-September 2nd, 2024
-September 8th, 2024
Staffing coordinator K acknowledged the facility had difficulty finding RN coverage for weekends.
O3/5/25 at 12:14 PM the Director of Nursing (DON) was interviewed and said there have been times when a RN was not available, and the expectation is that there is 8-hour RN coverage 7 days per week. The DON agreed the resident population consisted of residents with tube feedings, intravenous medications and the facility had previous residents with tracheostomies that would require RN supervision.
On 3/5/25 at 12:14 PM RN coverage policy was requested.
On 3/05/25 at 1:33 PM the DON was interviewed and said the facility does not have a RN coverage policy and that the facility refers to the Center for Medicare and Medicaid Services guidelines.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to: 1. Properly clean surfaces in the kitchen that were visibly soiled; 2. Properly seal food in the freezer; 3. Ensure pans wer...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to: 1. Properly clean surfaces in the kitchen that were visibly soiled; 2. Properly seal food in the freezer; 3. Ensure pans were cleaned and air dried before stacking; 4. Properly maintain resident refrigerator; and 5. Ensure reusable resident meal service ware was properly sanitized. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness.
Findings include:
During the initial tour of the kitchen on 3/3/25 at 8:28 AM with Dietary Manager, (DM) G, the following was observed:
1. The inside of the ice scoop container was soiled with food debris and contained in a plastic sandwich bag.
2. The sides and bottom vents on the vegetable reach-in freezer and supplement reach-in freezer were soiled and stained with food debris.
3. The meat freezer contained an opened box of turkey sausage that was not adequately sealed exposing the contents to the freezer air.
4. A wet 1/2 pan and full-size pan soiled with food debris were observed nestled and stored with other pans in the clean pot/pan storage area.
5. The top and middle cooking utensil drawers were soiled with grease and food debris. DM G stated, They could use a wipe.
6. A double bar above the three-compartment sink was soiled with a buildup of grease, dust, and grime. A dust bunny was observed falling towards the three-compartment sink.
On 3/3/25 at approximately 10:00 AM, DM G said the dishwasher temperature was not consistently reaching the temperature to properly sanitize and therefore disposable table wear would be used for lunch service.
During a return visit to the kitchen on 3/3/25 at 11:30 AM, a maintenance worker was observed on a ladder at the three-compartment sink cleaning the soiled double bar and a vent located above the double bar. The maintenance worker used a putty knife to clean inside of the vent. Several ribbons, resembling twisted locks of hair, likely composed of grease, dust, and grime were observed being removed from the vent during the cleaning process.
On 3/3/25 at 12:20 PM, during lunch meal service, resident meals were served using single-use disposable tableware and eating utensils, however, reusable meal trays and dome plate covers were being used.
On 3/4/25 at 9:15 AM, DM G said the kitchen vent cleaned yesterday was supposed to have been cleaned one to two months ago, but the amount of debris that was removed yesterday could not have built up that quickly. DM G said the vent system could not have been effectively operating with the amount of dust build up.
On 3/4/25 at 10:48 AM, the contents of the 3rd floor resident refrigerator were observed with Registered Nurse (RN) C. The following was noted in the refrigerator:
- a plastic grocery bag containing food in a disposable food container was labeled with something that looked like FeF4. The bag was undated.
- an opened snack pack of meat, cheese, and crackers was undated and not labeled with a resident's name.
- an eight-ounce carton of 2% milk was labeled with a sell by date of 2/9/25.
The freezer compartment contained an opened 48-ounce container of ice cream which was not labeled with a resident's name.
A thermometer was not placed in the refrigerator or freezer. There was no log used to document the temperature of the refrigerator and freezer.
On 3/4/25 at 11:20 AM, DM G affirmed that the dish machine was out of service between breakfast and lunch on 3/3/25.
On 3/4/25 at 11:25 AM, Dietary Aide (DA) F was interviewed and said that yesterday between breakfast and lunch the dish machine water temperature was not hot enough to sanitize the dishes. DA F said yesterday between breakfast and lunch she washed the reusable meal trays and dome plate covers in soapy water in a one-compartment sink and then ran the trays and plate covers through the dish machine.
On 3/4/25 at 11:30 AM, DM G said the reusable meal trays were sanitized using germicidal alcohol wipes. The reusable dome plate covers were not sanitized prior to lunch meal service. DM G said the plate covers should have been dipped in the three-compartment sanitizing sink.
On 3/4/25 at 3:04 PM, when queried about the insufficient cleanliness of the kitchen, DM G stated, I probably should have redone the cleaning assignments.
On 3/5/25 at 11:31 AM, the Director of Nursing (DON) said that a thermometer should have been in the resident refrigerator and freezer, a temperature log maintained, and food should have been labeled and dated.
On 3/5/25 at 3:30 PM, the Nursing Home Administrator said the vent above the kitchen three-compartment sink draws in air that is filtered and recirculated back into the building. The NHA said there was no excuse for a dirty kitchen.
On 3/5/25 at 3:30 PM, the NHA and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
A review of the 2013 FDA Food Code documented the following:
-Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.
- Section 4-602.13, Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
- Section 4-703.11, Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized.
- Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.
- Section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in the c...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in the coffee machine and walk-in cooler not being protected against contamination from sewage or other sources of contamination.
Findings include:
On 3/3/25 at 8:28 AM, during the initial tour of the kitchen with Dietary Manager (DM) G, the following was observed:
- The drain line from the coffee machine was partially positioned on a metal plate which resulted in a direct connection between the coffee machine drain line and the floor drain.
- The drain line from the walk-in cooler was observed to not have an unobstructed vertical space between the end of the walk-in cooler drain line and the floor drain.
When queried about an air gap for the coffee machine and walk-in cooler, DM G stated, There should have been an air gap.
On 3/5/25 at 11:47 AM, the Nursing Home Administrator (NHA) said the coffee machine drainpipe needed to be moved over a couple of inches and the walk-in cooler drain was not properly air gapped.
On 3/5/25 at 3:30 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
The 2013 FDA Food Code was reviewed and revealed the following in Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely personal care for one of (R15) four resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely personal care for one of (R15) four residents reviewed for ADL's resulting in untimely assistance with bathing, dressing, and transferring to their wheelchair and the resident verbalizing feelings of frustration and anger.
Findings include:
On 10/2/24 at 08:56am, R15's call light was on, and the resident was observed lying on their back, sheet and blanket was not covering the right side of R15's body, wearing a soiled brief and a faded black t-shirt with food stains across the front of the shirt. There was an odor of stool. R15 lips were dry with skin peeling. In addition, the resident face had dried food within their beard. R15 indicated they needed to be cleaned up due to an accident in their brief.
On 10/2/24 at 09:40am, an unknown certified nurse aide (CNA) was observed with R15 changing their brief. During this time of care, staff did not perform bathing nor dressing the resident. R15 stated that they were waiting for the CNA to come back with the Hoyer lift.
On 10/2/24 at 10:45am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. The resident denied being bathed at this time.
On 10/2/24 at 11:33am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. R15 said, I'm waiting for the aide to wash me and get me up.
On 10/2/24 at 11:51am, Licensed Practical Nurse LPN A was interviewed and asked if R15 was going to be dressed and assisted out of bed. LPN A said, (R15) has diarrhea and need to stay in bed because it doesn't make sence to keep getting (R15) in and out of bed.
On 10/2/24 at 2:54pm, R15 was observed in bed with their eyes opened. R15 was wearing a brief and the same stained black t-shirt. The resident said, I'm getting mad now.
On 10/3/24 at 08:06am, R15 was observed in bed, wearing a brief and the same stained black t-shirt. R15 lips were dry with skin peeling. In addition, the resident face had small pieces of dried food within their beard. R15 stated that staff never assisted with bathing and dressing. R15 stated, I'm frustrated because they never got me out of bed and they didn't helped me wash-up .I'm tired of laying in this bed .and I'm mad because I forgot to call my brother yesterday to wish him happy birthday because I was so upset trying to get somebody to help me get up.
On 10/3/24 at 09:55am, R15 was observed in bed with their eyes closed. R15 was wearing the same stained black t-shirt.
A review of R15's medical record indicated that the resident was initially admitted to the facility on [DATE] with the diagnosis of Peripheral vascular Disease, Cerebral Infarction, Hypertension, Immunodeficiency, and Non-Pressure Chronic Ulcer.
A review of R15's Quarterly Minimum Data Set (MDS) assessment, dated 7/5/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognition is intact). MDS Section GG - Functional Abilities.
A review of R15's care plan noted I have an ADL (Activities of daily living) self-CVA care deficit secondary to history of CVA (Stroke) with impaired mobility. Date Initiated: 02/19/2024. Interventions noted the following:
BATHING- I need 1 person assist to bath.
Bed Mobility- I need 2 person assist.
Personal Hygiene/Oral Care: I require (1) staff participation with personal hygiene and oral care.
Dressing: I require (assistance with choices, physical assistance) to dress.
Transfer- Hoyer lift for transfers X 2 person.
Mobility: I use a wheelchair for locomotion.
Bed Mobility-Extensive assistance.
On 10/03/24 at 11:36am, the Nursing Home Administrator (NHA) was interviewed and informed that R15 was asking to be dressed and get out of bed since yesterday, resident remained in bed with same soiled t-shirt and not wearing pants. The NHA stated The expectation is that staff dress and assist all residents out of bed.
A review of the facility's policy Activities of Daily Living dated 2/25/24 noted the following:
The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.
Care services will be provided for the following activities of daily living:
1.
Bathing, dressing, grooming, and oral care;
2.
Transfer and ambulation;
3.
Toileting.
Aug 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145699.
Based on interview and record review the facility failed to ensure adequate assista...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00145699.
Based on interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of four residents reviewed for falls, resulting in a fracture of the right rib and hospitalization.
Findings include:
Review of an admission Record revealed, R601 originally admitted to the facility on [DATE] with pertinent diagnosis which included hemiplegia and hemiparesis following a cerebral infraction. R601 discharged on 7/1/24 due to a fall and returned to the facility on 7/5/24 with the diagnosis of Fracture of one rib, right side.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 8 out of 15 and had impairment on one side of the upper and lower extremities.
Review of a nurse's progress note with a date of 7/1/24 at 4:13 p.m. revealed, Event occurred on 07/01/2024 11:30 AM. res was being lifted in hoyer lift and the hooks from the hoyer pad slipped off the hooks of the hoyer lift and res fell to the floor at bedside in his room .(sic)
Review of a nurse's progress note with a date of 7/2/24 at 3:10 p.m. revealed, FALL: Writer alert by staff that resident had c/o (complaint) chest pains. Upon immediate assessment resident stated that he had chest pains, and he had a fall. Physical assessment revealed pain 10/10 to right side and chest pains 3/10 . Physician notified and gave order for hospital transfer for post fall evaluation .
Review of a care plan revealed R601 had the focus, I have an ADL self-care deficit secondary to history CVA with impaired mobility initiated 7/15/222. Intervention included, I require total assistance with transfers with an initiated date of 7/29/22.
Review of a hospital H&P (History & Physical) report dated 7/1/24 revealed, R601 presented to emergency department after a fall from Hoyer lift on the AM of 7/1. A chest x-ray suggested R601 had a fractured right seventh rib.
In an interview on 8/1/24 at 12:50 p.m., Certified Nursing Assistant (CNA) F reported she transferred R601 with a Hoyer lift without assistance. CNA F reported R601 fall on the bed frame. CNA F reported being aware that mechanical lift transfers required two people and stated, I was irresponsible and got him up by myself, I did not ask for help because there was nobody.
In an interview on 8/1/24 at 1:25p.m., the Director of Nursing (DON) reported R601 was sent to the hospital after a Hoyer lift transfer that resulted in fractured right rib. The DON reported CNA F acknowledged that she made a mistake by not waiting for assistance when transferring R601with the Hoyer lift. The DON reported staff are trained upon hire and receive a competency for Hoyer lift use annually. The DON reported the importance of using two people for mechanical lift transfers is to maintain safety.
In an interview on 8/1/24 at 2:04 p.m., the NHA (Nursing Home Administrator) reported being made aware that R601 had a fall out of the lift on 7/1/24. The NHA then reported two people are required for mechanical lift transfers.
Review of a Mechanical Lift policy revised 12/2018 documented, A mechanical lift will be used to transfer any resident that is totally dependent and immobile . General Guidelines . 2. Do not operate the Hoyer lift alone. Assistance will be needed to guide the resident to another location . 5. The Hoyer lift should always be in good operating condition .
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:
1.
R601 was immediately assessed by the charge nurse and neuro checks, pain assessment and skin assessments completed.
2.
All mechanical lifts were inspected. The malfunctioning Hoyer lift was removed and stored in a non-accessible area away from staff and new Hoyer lifts were ordered.
3.
The Administrator and Director of Nursing provided a 1:1 education for the assigned CNA on the Fall Prevention Program, Mechanical Lift, Abuse/Neglect/Exploitation, and Change of Condition polices.
4.
A facility audit was conducted and like resident care plans were updated.
5.
The Administrator and DON reviewed the Fall Prevention Program, Mechanical Lift, Abuse/Neglect/Exploitation, and Change of Condition polices and were deemed appropriate.
6.
All Certified Nurse Aids were educated on Mechanical Lift Transfers with return demonstration to ensure competency with emphasis on needing 2 persons when using a Hoyer lift.
7.
All staff was educated on the Abuse/Neglect/Exploitation policy.
8.
The Unit Manager/Designee will conduct audits on observations of mechanical lift transfers on 3 residents M-F weekly for 4 weeks to ensure compliance. Results of these audits will be reported to the QAPI Committee for further review and recommendations
9.
The Administrator/Designee will audit all Hoyer lifts for functionality M-F for 4 weeks to ensure safety of residents. Results of these audits will be reported to the QAPI Committee for further review and recommendations
The facility was able to demonstrate monitoring of the corrective action and maintained compliance.
Feb 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accommodating call light was provided for o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accommodating call light was provided for one resident (R4) of one resident reviewed for accommodation of needs, resulting in R4's inability to use the call light and the potential for unmet care needs.
Findings include:
On 1/30/2024 at 10:28 a.m., R4 was observed lying in bed alert and able to be interviewed. Observed R4 left eye closed and no call light in reach. R4 call light was on the floor behind the bed. R4 bilateral hand was observed in a fist like position which appeared to be contracted and unable to extend when asked to so. During an interview regarding the capability of using a call light, R4 reported being unable to push the button on the call light. R4 stated, My eye has been burning for a couple of days and would have let someone know that it is still burning if she was able to use the call light. R4 added that no staff asked her about her eye on 1/30/24.
On 1/30/2024 at 10:33 a.m., Certified Nursing Assistance (CNA) F entered R4's room and place the call light in reach of R4. During this time R4 demonstrated not being able to push the button on the call light for assistance. CNA F was interviewed and stated, No, she can't use this call light because of her hands. CNA F was asked should the resident have a call light that can be used. CNA F stated, The call light is for when the residents need something or to call for help, she can't use hers, but she can tell you what she wants or needs.
On 1/30/2024 at 10:55 a.m. Licensed Practical Nurse (LPN) G entered R4's room, placed the call light in R4' hand and asked R4 to push the button on the call light. R4 tried to push the button on the call light unsuccessful and stated, I can't (with some facial grimaces while trying to push the button). LPN G stated, I see what you mean. I will see about getting her another kind of call light with a flat surface, a touch call light.
On 2/1/2024 at 2:49 p.m., during an interview regarding a specialty call light for R4, the Director of Nursing (DON) said R4 should have an alternate call light because her call light is not effective. The DON stated, I believe it's a motion call light or something.
According to the electronic medical record, R4 was initially admitted to the facility on [DATE] with diagnoses of muscle wasting atrophy, myalgia, major depressive disorder, contracture of left and right elbow, and schizoaffective disorder. According to the quarterly Minimum Data Set (MDS) with a reference date of 7/18/2023 indicated R4's BIMS (brief interview for mental status) was not scored, range of motion 2/2 indicating impaired limbs on both sides of upper and lower, and 0/1 indicating R4 is total dependent for oral hygiene, toileting, showers/baths, transfers, and bed mobility.
Review of the 2/1/2024 start date Activity Daily Living (ADL) care plan documented, I have an ADL self-care performance deficit secondary to functional quadriplegia and diagnoses of depression. Interventions: Bathing-I am dependent on staff to bathe me . I am total dependent on staff for dressing, and oral care .Encourage me to use call light for assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care and oral care for one resident (R4)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care and oral care for one resident (R4) out of four residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADLs needs.
On 1/30/2024at 11:05 a.m., R4 was observed lying in her bed alert and able to be interviewed. Observed R4 with long dirty fingernails, hair appeared not groomed and matted, and teeth with what appeared to be food particles and mouth odor. During an interview, R4 was asked to recall the last time the staff assisted with scheduled showers, oral care, washing and hair grooming. R4 stated, I can't remember. R4 said I would like to get my fingernails cut.
On 2/1/2024 at 9:33 a.m., R4 was observed lying in bed with long dirty fingernails, hair appeared not groomed and matted, unable to observe teeth due to a staff assisting R4 with breakfast.
After breakfast at 9:59 a.m., R4 stated, I can't remember the last time I got up out of bed to have a shower, had my teeth brushed or my mouth rinsed out, or had my fingernails cut or clean. I need a makeover. I like to have clear nail polish on my fingernails, I want my fingernails cut and clean. I want my hair to be washed and to take a shower.
According to the electronic medical record, R4 was initially admitted to the facility on [DATE] with diagnoses of muscle wasting atrophy, myalgia, major depressive disorder, contracture of left and right elbow, and schizoaffective disorder. According to the quarterly Minimum Data Set (MDS) with a reference date of 7/18/2023 indicated R4's BIMS (brief interview for mental status) was not scored, range of motion 2/2 indicating impaired limbs on both sides of upper and lower, and 0/1 indicating R4 is total dependent for oral hygiene, toileting, showers/baths, transfers, and bed mobility.
Review of the 2/1/2024 start date Activity Daily Living (ADL) care plan documented, I have an ADL self-care performance deficit secondary to functional quadriplegia and diagnoses of depression. Interventions: Bathing-I am dependent on staff to bathe me. Check nail length and trim and clean on bath days and as necessary. I am total dependent on staff for dressing, and oral care .
On 2/1/2024 at 2:49 p.m., during an interview regarding R4's oral care and nail care, the Director of nursing (DON) reviewed R4's electronic medical record and reported there was no docuented evidence that Certified Nurse Assistants provided oral and nail care for R4.
According to the facility's undated Personal hygiene and bed making policy, Maintenance of daily oral hygiene, including brushing, flossing, and rinsing, is essential for the prevention and control of plaque associated oral disease. In addition to preventing inflammation and infection, oral hygiene is general promotes comfort, ease of swallowing for better food intake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement skin care treatments for one resident (R59)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement skin care treatments for one resident (R59) out of three residents reviewed for non-pressure related skin conditions, resulting in the potential for delay in healing.
Findings include:
During interviews on 1/30/24 at 8:36 AM and 1/31/24 at 11:16 AM, Resident #59 (R59) was observed in his room awake and lying in bed. R59 stated, The foot doctor was supposed to order some cream, but I ain't got it yet. R59 denied that staff had applied lotion or cream to his right leg. R59 denied that he had refused the application of lotion. The skin on the front of R59's lower right leg appeared to be very dry and scaly.
On 1/31/24 at 11:22 AM, interviews and observations were conducted with Licensed Practical Nurse (LPN) D. The contents of the medication cart and treatment cart for R59's unit were checked and Amlactin lotion (medication used to treat dry, scaly skin conditions) for R59 was not in either cart. LPN D said she ordered medications yesterday. A facility document titled, Consolidated Delivery Sheets, dated 1/30/24 was reviewed with LPN D. This document contained a list of medications that LPN D ordered. Amlactin lotion for R59 was not listed on this document.
On 1/31/24 at 11:30 AM, when an observation of R59's skin was conducted with LPN D, she described his skin as dry and flaky with scabs. LPN D asked R59 if anyone applied anything on his leg yesterday. R59 stated, No. LPN D said the treatments have not been effective or not applied effectively. LPN D stated, I've been here since the 17th (of January 2024) and there has been no change (in R59's skin condition). I think his leg needs to be re-evaluated. A doctor should come in and review it. LPN D said the doctor should have been notified.
A review the clinical record for R59 documented an admission date of 5/21/20 and readmission date of 11/29/22. R59's diagnoses included chronic obstructive pulmonary disease and type 2 diabetes mellitus. A physician order, dated 12/20/23, indicated the following: Amlactin daily external lotion 12%, apply to both legs topically one time a day for dry skin. A Minimum Data Set (MDS) assessment dated [DATE] documented moderate cognitive impairment. Record review of R59's I have an actual skin impairment and increased risk for skin impairment secondary to diabetes and vascular disease, up in chair most of the day and poor dietary choices care plan created on 11/29/22 documented in part, Keep skin clean and dry. Use lotion on dry skin.
A prescription from the Family Foot and Ankle Specialist, dated 12/19/23, documented in part, Amlactin 12% Cream .apply to affected sites daily.
A review of a facility document provided during the survey titled, Personal Hygiene and Bed Making, documented in part the following:
- Common Skin Problems: Dry skin
- Characteristics: Flaky, rough texture caused by lack of moisture .most common on anterior (front) surfaces of lower legs .
- Implications: Skin may crack, bleed, and become inflames. As a result, redness .and discomfort may develop.
- Interventions: Effective treatment of dry skin includes .use of moisturizer.
During an interview on 1/2/24 at 2:36 PM, the Director of Nursing (DON) said the Amlactin lotion should have been given as prescribed and if it was ineffective, nursing should have notified the physician.
On 2/1/24 at 4:50 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to date two opened respiratory inhaler devices of one res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to date two opened respiratory inhaler devices of one resident (R30), resulting in the potential to administer outdated medications with incorrect effectiveness.
Findings include:
Medication Cart 1st-Floor
On 1/31/2024 at 9:00 a.m. during a medication administration observation (Med-Pass) with Licensed Practical Nurse (LPN) D a Respiratory inhaler (Spiriva Respimat inhaler aerosol) was observed opened with no date.
LPN D confirmed there was no date written and was asked should the respiratory inhaler be dated. LPN D observed the pharmacy instruction written on the medication package to Date after opened and said, yes, it should have been dated. LPN D said the discard instruction is written on the package by pharmacy to discard after 10/23/2024, it's not expired but I don't know when it was opened.
LPN D continued to pull medication from the medication cart and observed a second respirator inhaler (Advair Diskus) not dated. LPN D confirmed that there was no date on the inhaler, and it should have been a date. Review of the pharmacy instruction written on the medication package to Date after opened. No written discard date on the package observed.
On 2/1/24 at 2:49 p.m. the Director of Nursing (DON) was interviewed. The DON was informed of the two respiratory inhalers on the medication cart opened with no date. The DON said the medications should be dated at the time its opened.
According to the facility's June 2019 Medication Storage in the Facility policy: Medication and biologicals are stored safely, securely, and properly .
Medication room [ROOM NUMBER]nd Floor
On 1/31/24 at 1:00 p.m. the second-floor medication room was observed with a refrigerator (empty) with a temperature log that was dated for the month of March 2023.
There was a dingy dark grey jacket on a metal rack next to medical supplies (barriers, syringes, specimen cup).
The floor was dirty with paper, unpackaged swabs, dried food, and plastic wrapping.
There was hanging pole that had dried white substance on the base.
An oxygen cylinder was propped against the wall between two fire extinguishers and a metal rack with a stand.
The sink was filled with approximately four clear plastic bags with medical supplies (two bags with intravenous medication with resident's name on them and syringes).
On 2/1/24 at 2:00 p.m. Unit Manager J was interviewed. Unit Manager J about the condition of the medication room. Unit Manager J said the refrigerator was brought from the basement yesterday and the temperature log was not replaced with a current one. At that time, the refrigerator was opened and revealed various medications in it. Unit Manager J began to instruct staff to clean the medication room and stated, I can't fix something I don't know about. Unit Manager J did not offer any additional responses.
3rd Floor Medication Cart
On 1/31/24 at 2:07 p.m. the back hall medication cart was observed with an inhaler (Albuterol Sulfate Inhalation Solution, 0.083%) that was opened and not dated.
On 1/31/24 at 2:09 p.m. an inhaler (Budesonide-Formoterol 160-4.5) was opened and not dated.
On 1/31/24 at 2:11 p.m. a tube of a topical pain reliever (Diclofenac Sodium) was opened and used. The tube had a label on it with a space to write the date it was opened. The space was blank.
On 1/31/24 at 2:13 p.m. LPN K was interviewed and said the medications belonged to a resident that was sent to the hospital and the medications were not taken out of the medication cart. The resident returned to facility and the medications were ordered and were also put in the medication cart, The old medications should have been taken out.
LPN K did not offer an answer to the missing dates of the opened and used medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly
Findings include:
On 1/31/24 at 1:06 p.m. an observation of the medication room...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly
Findings include:
On 1/31/24 at 1:06 p.m. an observation of the medication room located on the second floor of the facility revealed an oxygen cylinder without a stand propped against the wall in the corner next to two fire extinguishers and a metal rack. Near the top of the oxygen cylinder regulator, the red needle was on 0 in the REFILL area (within or just outside of the red area, the cylinder is close to empty). This indicated the cylinder was not empty of oxygen.
On 2/1/24 at 2:02 p.m. Unit Manager J was interviewed regarding the oxygen cylinder inappropriately stored in the medication room. Unit Manager J directed a staff person to remove the cylinder while stating, I didn't know this was in here. This should not be in here.
On 2/1/24 at 3:11 p.m. the Director of Nursing was interviewed. The DON said the Central Supply staff person was responsible for removing oxygen equipment out of the medication rooms and ensure they are stored and placed safely.
Review of the facility's policy titled Oxygen Safety dated 1/11/21 documented the following: Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry . Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Resident #7
During an interview on 1/30/24 at 10:46 AM, Resident #7 (R7), who was alert and oriented, stated, my food is not warm or it is cold.
During an interview on 2/1/24 at 3:09 PM, the Director...
Read full inspector narrative →
Resident #7
During an interview on 1/30/24 at 10:46 AM, Resident #7 (R7), who was alert and oriented, stated, my food is not warm or it is cold.
During an interview on 2/1/24 at 3:09 PM, the Director of Nursing (DON) was informed that R7 said his food and coffee were often cold. The DON said she would speak with the dietary manager about this concern.
A review of the facility policy titled, Food Quality and Palatability, dated 7/23/21, documented in part the following:
- Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature.
- Proper (safe and appetizing) temperature: food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns.
On 2/1/24 at 4:50 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.
This citation pertains to Intakes MI00141917.
Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for residents served from a first-floor meal cart and specifically R7 from the third floor, resulting in dissatisfaction with the meal experience.
A complainant reported to the State Agency that the facility failed to serve palatable food.
During an observation and interview on 1/30/24 at 12:57 PM, the last tray on a first-floor meal cart was obtained and used as a test tray. License Practical Nurse (LPN) D was present during the testing of food temperatures on the lunch tray. The following temperatures were obtained using a metal stem thermometer:
- BBQ chicken: 103ºF (Fahrenheit)
- Mixed vegetables: 96ºF
- Rice: 98ºF
LPN D physically touched the mixed vegetables and rice and stated the food was not warm enough that you would enjoy eating it.
During an interview on 1/31/24 at 2:57 PM, Dietary Director (DD) B said the temperature of hot food when it reaches the floor should be 140 degrees.
During an interview on 2/1/24 at 12:46 PM, the Nursing Home Administrator (NHA) stated, We've identified food temperatures as an area in need of attention. We are in the process of getting new food carts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents observed duri...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents observed during dining observations, resulting in resident dissatisfaction.
Findings include:
A review of a facility document titled, Resident Meal Service Times, dated 11/17/23, revealed that meal trays were to be delivered to the first-floor residents for breakfast and lunch at 7:50 AM and 11:45 AM respectively. This document further indicated to Please allow + or - 10 minutes between meal delivery times.
During an observation on 1/30/24 at 8:26 AM, breakfast had not been served to the residents residing on the first floor.
On 1/30/24 at 9:20 AM, Resident #60 (R60) was observed alert, fully oriented, and in his room. R60 indicated he had not been served breakfast yet and stated, I'm hungry. Breakfast meal trays were delivered to the first floor at 9:16 AM. R60 received his breakfast at 9:24 AM.
During an observation on 1/30/24, lunch meal trays were delivered to the first floor at 12:52 PM.
During an observation on 1/31/24, breakfast meal trays were being served to the residents residing on the first floor at 8:30 AM.
During an interview on 1/31/24 at 2:57 PM, Dietary Director (DD) B indicated she was aware that meals were being served late. DD B stated, They were late today. DD B stated, The bottom line is that there is not enough staff to get meals out on time. We need at least one more person.
During an interview on 2/1/24 at 12:46 PM, the Nursing Home Administrator (NHA) said an acceptable window for late meals being served is 30 minutes after the scheduled time. The NHA indicated that waiting over an our past the scheduled meal time is unacceptable.
On 2/1/24 at 4:50 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
This citation pertains to Intakes MI00141917.
Based on interview and record review, the facility failed to consistently utilize the services of a Registered Nurse (RN) for eight consecutive hours per ...
Read full inspector narrative →
This citation pertains to Intakes MI00141917.
Based on interview and record review, the facility failed to consistently utilize the services of a Registered Nurse (RN) for eight consecutive hours per day (24-hour period), seven days a week, resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes, affecting the 89 residents who resided in the facility.
Findings include:
A complainant reported to the State Agency concerns with nursing staffing levels.
On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staffing Coordinator (SC) E who was responsible for scheduling nursing staff for the facility. A review of nursing schedules during the periods of 11/15/23 to 11/30/23 and 1/2/24 to 1/15/24 revealed there was no RN coverage per day (24-hour period) for the following dates:
11/15/23, 11/17/23, 11/20/23, 11/23/23, 11/24/23, 11/25/23, 11/26/23, 11/28/23, 11/29/23, 11/30/23, 1/2/24, 1/4/24, 1/7/24, and 1/12/24.
On 2/1/24 at 2:34 PM, the Director of Nursing (DON) said the building should be staffed with eight hours of RN coverage every single day. The DON was aware that they are not meeting that expectation. The DON reviewed the nursing schedules for the periods of 11/15/23 to 11/30/23 and 1/2/24 and 1/15/24 and concurred with the findings of no RN coverage as previously indicated.
On 2/1/24 at 4:50 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes ...
Read full inspector narrative →
Based on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 89 residents that reside in the facility.
Findings include:
During an interview and record review on 2/01/24 at 1:58 PM, the QAPI program was reviewed with the Nursing Home Administrator (NHA). The NHA revealed that QAPI team members met monthly and included managers and interdisciplinary team members. When queried if the medical director attends the required quarterly QAPI meeting the NHA stated, The medical director did not participate in any of the 2023 QAPI committees or any meetings for 2024 nor did his representative.
Record review of the provided 12 QAPI attendance records dated January 2023 through September 2023, and 3 undated sign in sheets next to the Medical Director title were blank.
Review of the facility's policy titled, Quality Assurance and Performance Improvement dated 10/20/1989, revised/reviewed 10/22 revealed in part The QAPI program includes the establishment of a Quality Assessment and Assurance Committee and a written QAPI plan. The QA committee shall be interdisciplinary and shall consist at a minimum the director of nursing, the medical director or his/her designee .meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the first-floor shower room and dirty utility ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the first-floor shower room and dirty utility room were maintained in a clean and sanitary manner, resulting in the residents' environment not being homelike and the potential for spread harmful pathogens.
Findings include:
During the initial tour of the facility on 1/30/24 beginning at 7:15 AM, the following observations were made on the first-floor housing unit:
- two used and soiled towels were on the floor in the unit shower room near room [ROOM NUMBER].
- the soiled utility room near room [ROOM NUMBER] contained a trash can, approximately 44 gallons in size. The trash can overflowed and was stacked and packed with bagged and loose garbage including several disposable drinking cups and a used green incontinence bed pad. Two bags of garbage and two pairs of used disposable gloves were observed on the floor next to the trash can. A commercial mop bucket was stored containing dirty mop water.
During an observation and interview of the trash in the soiled utility room on 1/30/24 at 7:29 AM, Certified Nurse Aide H stated, They need to pull it.
During an interview on 2/1/24 at 12:46 PM, the Nursing Home Administrator (NHA) said the towels on the floor in the shower room should have been picked up after a shower because of sanitation purposes. The NHA stated, It's everyone's responsibility to ensure infection control policies are adhered to. The NHA said the trash in the soiled utility room should have been picked up, and it is unacceptable for trash to be on the floor.
On 2/1/24 at 4:50 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.
Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 89 residents and its staff resulting in an increased chance of harm and the spread of harmful pathogens.
Findings include:
On 1/31/24 between 11:02 AM and 11:25 AM, during a tour of the laundry room and its support spaces the following observations were made:
An accumulation of dust and debris was observed on top and on the sides of both washing machines, underneath and behind both dryers, on the blades and grill of the wall mounted fan, on the furnace vent grates and its filters, and within the floor grates next to the washing machines.
Multiple soiled towels were observed on top of the washing machines.
The overhead light fixture above the dryers was observed with its light bulbs missing.
Floor tiles/ a flooring material was observed deteriorated and missing in multiple areas throughout the laundry room.
One of two washing machines was observed in a non-functional state, and one was actively leaking on the floor while in use.
Multiple blankets and clothing items were observed stored on the floor in the Laundry's lost and found room.
On 1/31/24 at 11:10 AM, upon interview with Laundry Aide, staff A, on the current state of the
washing machines they stated, we have only had the one for a while now, and it does leak, but it works well so we just keep using towels to soak up the water during the day. At this time the surveyor inquired with staff A on what the facility would do if the leaking washing machine stopped working or needed to be repaired to which they replied, I really don't know. Buy new ones or get a laundry company to take our stuff I guess.
On 1/31/24 at 11:15 AM, upon interview with staff A, the surveyor asked who was responsible for the cleaning in the laundry room to which they replied, some of it is maintenance, housekeeping, and some of it is us.
On 1/31/24 at 11:24 AM, upon interview with staff A, on the current state of the lost and found room they stated, it's bad. I can't even get to the things to figure out what we have to give to the residents, and people just keep dropping more stuff off.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
This citation pertains to intakes MI001134882 and MI00134896.
Based on interview and record review the facility failed to prevent the misappropriation of funds for one (R504) of three residents review...
Read full inspector narrative →
This citation pertains to intakes MI001134882 and MI00134896.
Based on interview and record review the facility failed to prevent the misappropriation of funds for one (R504) of three residents reviewed for abuse, resulting in $2,400.00 of unauthorized deductions from R504's bank account.
Findings include:
The State Agency (SA) received a complaint and a FRI (facility reported incident) that R504 had $2,400.00 deducted from her bank account by a facility staff member without her authorization.
On 3/21/23 at approximately 10:00 AM the Nursing Home Administration (NHA) said on 2/10/23 R504 notified the Director of Nursing (DON) that Certified Nursing Assistant (CNA) A and CNA B had taken $2,400.00 out of her bank account. An investigation was initiated immediately that included reporting the incident to the SA and local Police Department. The investigation revealed R504 had previously asked CNA A to pay her (the resident's) cell phone bill and gave CNA A her debit card information to pay the bill. CNA A opened a 'Cash App' (Software application installed on a cell phone to send and spend money from a bank account) on her (CNA 'A's) phone and then made several unauthorized deductions from R504's bank account to herself and another unidentified person that totaled $2,400.00. The NHA said both CNA A and CNA B had been suspended during the investigation. The investigation substantiated that CNA A had deducted money from R504's bank account without authorization from R504 and was subsequently terminated from employment at the facility. It was determined that CNA B was not involved in any of the unauthorized deductions.
According to the Electronic Health Record R504 has resided at the facility since 5/23/2022 and is her own responsible party that included financial responsibilities. R504 was identified to have moderately impaired cognition status with a BIMS ( brief interview for mental status) score of 10/15 and required supervision from one staff member for most activities of daily living.
On 3/21/23 at 12:40 PM R504 was seated in her room eating lunch. During an interview R504 said that CNA A took 2,400.00 out of her bank account last month. R504 pulled out her bank statements and pointed out several unauthorized 'Cash App' deductions from 12/2022 through 2/2023 that were sent to CNA A and another unidentified person by means of 'Cash App'. R504 said, I knew it was her (CNA A) because I asked her to help me pay my cell phone bill before. She paid my cell phone bill with my debit card and must have kept the information on it. I think she took a picture of the card or something like that because we were in my room the whole time she paid my cell phone bill. When I went to the bank to get some money they told me there was no money in it. The bank gave me the statements and it showed all these 'Cash App' deductions to CNA A and some other person. I don't even know what that it is and I have never used it. I was so upset and cried that whole day. I can't believe she would do that. The police came and so did another guy from the State to take my statement. My daughter and I went back to the bank and they are going to reimburse my money since it was fraud. R504 said she was aware that CNA A had been terminated and that CNA B had not been involved with the incident. R504 went on to say she felt safe in the facility and did not have any concerns with the current staff in the facility.
CNA A did not respond to a request for an interview prior to the survey exit date.
A review of the facility's policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised April 2017 documented:
-Residents have the right to be free from theft and/or misappropriation of personal property.
-Our facility will exercise reasonable care to protect the resident from property loss or theft, including providing measures to safeguard resident valuables from easy public access.
Nov 2022
7 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0578
(Tag F0578)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00126045.
Based on interview and record review, the facility failed to adhere to one r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00126045.
Based on interview and record review, the facility failed to adhere to one resident's (R74) Do Not Resuscitate (DNR) code status and failed to verify one resident's (R221) documented evidence (such as a medical power of attorney, patient advocate, legal guardianship, or living will) that a family member was authorized to designate a DNR directive of six residents reviewed for advance directives, resulting in unwanted and unmet end of life wishes where CPR was performed on R74 and no CPR was performed on R221. The Immediate Jeopardy (IJ) was identified on [DATE] at 11:15 a.m., as a result of Cardiopulmonary Resuscitation (CPR is defined as-emergency procedure consisting of chest compressions in an effort to restore spontaneous blood circulation) being performed on R74 for approximately 25 minutes and no CPR being performed on R221, leading to the likelihood of other residents affected due to lack of adhering to code status that could lead to serious harm, injury, impairment or death.
The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:35 PM.
The Immediate Jeopardy began on [DATE].
A plan to remove the immediacy was requested.
The IJ was removed on [DATE], based on the facility's implementations of the plan of removal as verified by the survey team on site. Although the IJ was removed, the facility's deficient practice was corrected and remained isolated with no actual harm with potential for more than minimal harm.
Findings include:
Resident R74
A review of R74's clinical record revealed R74 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included: heart failure, schizoaffective disorder (mental health disorder), and kidney disease. Review of the annual Minimum Data set (MDS) assessment dated [DATE] documented R74 had severe cognitive impairment. According to the face sheet, R74's family member H was listed as emergency contact. Included in the record was court paperwork which documented R74's family member H was the Legal Guardian (LG).
Further review of the clinical record identified R74 as being a Do Not Resuscitate (DNR-No to CPR). The clinical record contained a facility document which had an X marked next to Do Not Resuscitate (DNR) which had been signed by R74's LG H on [DATE].
Review of a physician's order dated [DATE] documented, DNR with hospitalization.
Review of the [DATE] care plan documented, (R74) and responsible party have elected a DNR- with hospitalization Code Status with an intervention of; Ensure (R74's) comfort.
Review of R74's nursing progress note dated [DATE] at 6:00 AM, Resident observed unresponsive. No vitals noted. 911 was called. CPR in progress until Emergency Medical Services (EMS) arrived. EMS put on Cardio Pads while doing CPR. Resident had no vitals. Police was called for an investigation. They left police report number. Family was called, they chose (Name of) Funeral Home of (name of location). Doctor has been notified. At 7:54 AM, (Name of) Funeral Home picked up body.
In a phone call with the Director of Nursing (DON), Licensed Practical Nurse (LPN) I was interviewed. LPN I confirmed she was the nurse assigned to R74 on [DATE]. LPN I reported responding to R74's room and observed the resident unresponsive. LPN I indicated the resident was not doing well earlier in the shift and at that time confirmed the residents code status. When asked, LPN I reported R74 was a Full Code. LPN I confirmed performing chest compressions for about 2-5 minutes until EMS arrived. The nurse reported that when EMS arrived they performed CPR for approximately 20 minutes, they go through 5 cycles with a defibrillator. LPN I said after 5 unsuccessful cycles EMS called the hospital physician and pronounced the resident deceased . LPN I reported that all the residents in the facility are Full Code, with the exception of one resident who receives hospice services.
The DON told LPN I during the phone interview that when a resident is found unresponsive, one staff member should be confirming the resident's code status, while another staff member stayed with the resident getting vital signs. The DON reported that CPR should never have been initiated on R74.
Resident R221
A review of R221's clinical record revealed R221 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses which included: congestive heart failure, dementia, and high blood pressure. Review of the annual MDS assessment dated [DATE] documented R221 had severe cognitive impairment. According to the face sheet, R221 had a guardianship company as the Legal Guardian. Included in the record was court paperwork which documented R221's LG was appointed on [DATE].
Further review of the clinical record identified R221 as being a Do Not Resuscitate (No CPR). The clinical record contained a facility document which had an X marked next to Do Not Resuscitate (DNR). The document was signed by R221's family member O on [DATE] who was not the Legal Guardian.
Review of the electronic revealed there was no supporting documentation available which confirmed R221's family member O was an authorized legal representative to withhold treatment such as a medical power of attorney, or legal guardian.
A care plan revised on [DATE] titled, Advanced Directive established: I wish to be a DNR was reviewed. The interventions included provide all life sustaining measures (i.e. CPR .).
Review of R221's nursing progress note dated [DATE] (2 days after family member O's unauthorized signature on DNR papers) documented, Performing rounds at patient bedside. 0 movements observed. 0 response to verbal or tactile stimuli. 0 breath or heart sounds. 0 pulses palpable. Nurse Practitioner notified of patient status .DNR code status.
During an interview with the DON on [DATE] at 1:49 PM, it was confirmed that no CPR was performed on R221. R221 expired in the facility. The DON indicated not being employed by the facility at the time of the event and was unsure why the family member was allowed to sign the DNR papers, and not the Legal Guardian.
The DON was unsure why the care plan interventions were not reflective of the Resident/LG wishes and not updated.
Review of the facility's policy titled, Resident's Rights Regarding treatment and Advanced Directives revised 12/2020 documented, . 5. The facility will periodically assess the resident for decision-making abilities and approach the healthcare proxy or legal representative if the resident is determined not to have decision making capacities . 8. Decisions regarding advance directives and treatment will be periodically reviewed, the existing care instructions and whether the resident wishes to change or continue these instructions.
Abatement:
1. Identification of Residents Affected or Likely to be Affected:
Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed.
· The affected resident no longer resides in the facility.
· All current residents have the potential to be affected by this practice.
· The Medical Director was notified by the DON/designee of this event.
· The DON/designee will complete an audit of all current resident Advance Directives to ensure an Advance Directive is uploaded in the resident record and that the physician orders match the designation.
1. Actions to Prevent Occurrence/Recurrence:
Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed.
· All Advanced Directives were reviewed to ensure that the legal party responsible has signed and designated selection.
· The DON reviewed the Residents 'Rights Regarding Treatment and Advance Directives Policy and deemed it appropriate.
· The DON/designee will educate all Licensed Nurses on the Residents' Rights Regarding Treatment and Advance Directives Policy. All licensed Nurses will receive education prior to their next scheduled shift.
Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to place one resident's (R421) call light within reach of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to place one resident's (R421) call light within reach of one reviewed for accomodation of needs, resulting R421's inability to request help when needed.
Findings include:
A review of R421's electronic medical record (EMR) noted R421 was admitted to the facility on [DATE] with a medical diagnosis of stroke with left sided weakness and history of falls. Review of the physical therapy note dated for 10/31/22, stated the resident needed moderate to maximum assistance with gait due to gait unsteadiness.
On 11/1/22 at 11:05 AM R421 was observed lying in bed. The call light was observed hanging on the back wall light switch and out of R421's reach. R421 was heard yelling help repeatedly until 11:10 AM.
In an interview with R421 on 11/1/22 at 11:11 AM R421 stated, The staff do not answer my call light. I am handicapped and they need to answer it. It takes fifteen to twenty minutes for it to be answered.
On 11/2/22 at 11:48 AM R421's call light was observed out of reach. The call light was placed where the resident had to ambulate to the call light in order to use it.
On 11/3/22 at 08:44 AM R421's call light was observed out of reach. The call light was placed where the resident had to ambulate to the call light in order to use it. When asked about the use of the call light, R421 said, If I try to get up and get the call light I might fall.
In an interview on 11/3/22 at 8:59 AM Director of Therapy G, stated Resident R421 should not be standing or walking alone due to his physical therapy evaluation that was done on 10/31/22.
Review of the Call Lights System policy revised 12/2020 documented in part, Staff will ensure the call light is within reach of resident and secured, as needed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI001125054.
Based on interview and record review, the facility failed to notify the family member of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI001125054.
Based on interview and record review, the facility failed to notify the family member of one Resident (R#77) change in condition out of three residents reviewed for notification of changes in condition, resulting in the family of R#77 being unaware of a hospital transfe and the potential to cause a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include:
On 11/3/2022 at 2:54 p.m., an investigation was conducted regarding a complaint reported by R77 's concern family member (CFM). The (CFM) of Resident (R77) was interviewed via telephone on 11/3/2022 at 11:14 a.m. The (CFM) stated, The facility did not let me know my mother's health was declining. I walked in my mother's room on the day she went to the hospital (12/11/2021) for a visit and found her unresponsive. I called the ambulance myself to take her to the emergency room. A nurse came in my mom's room and said, She was showing some decline a few days ago. The (CFM) confirmed the facility did not notify her that on 12/5/2021, R77 was having pain to her left arm and an X-Ray was ordered.
According to R77's electronic medical record (EHR), R77 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute ischemic heart disease, hypertension, and monoplegia of upper limb following cerebral infarction affecting the right dominant side. Review of the Transfer Form revealed R77 was transferred to the hospital on [DATE]. There was no documentation that (CMF) was notified. According to the face sheet, R77's primary contact was the (CFM).
Review of the admission nurses progress notes dated 12/2/2021 documented, Resident presented to the facility alert with some confusion and forgetfulness. On 12/5/2021 R77 noted guarding left arm and complain of pain to the left arm and X-rays ordered. Review of the nurses progress notes did not reveal the guardian was notified of the status change. The nurses progress notes did not reveal the (CMF) was notified of R77's transfer to the hospital on [DATE].
Review of Social Services progress notes dated 12/7/2021 documented, Attempted twice to meet with R77 and was unable to get any information from her. She just sits there with a blank stare. Social service will attempt to contact the family to get information.
Review of the physician's orders revealed, Stat X-Ray of the skull left upper eyelid and left shoulder.
On 11/3/2022 at 3:15 p.m., while reviewing the EHR, the Director of Nursing (DON), was asked who were responsible for notifying the resident's guardian and families of any changes in condition. The DON stated, The nurses supposed to notify the guardian and families of any changes in condition and discharges. They are to document in the nurse's progress notes. The DON acknowledged that there was no documentation of the (CFM) being notified of any changes in condition or transfer to the hospital. I haven't been here that long so this will be one of the in-services I will be giving the nurses.
According to the facility's Change in Condition revised date 7/9/2020 policy: It is the policy of this facility to inform resident s/legal representative change in the resident's condition.
The DON did not present any documents verifying the (CFM) notification of changes in conditions prior to exiting the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that a resident was issued a NOMNC (Notice of Medi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that a resident was issued a NOMNC (Notice of Medicare Non-Coverage - Form 10123 [explanation of appeal rights]) and SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice - Form 10055) for one resident (R78) of three residents who were reviewed for notices of Medicare non-coverage and appeal rights, resulting in the resident not being fully informed of their Medicare rights or the potential liability of estimated cost in order to make a decision to appeal or continue therapy treatments.
Findings include:
A review of R78's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with multiple diagnoses that included history of personal falls at home and alcohol abuse. R78 was identified as his own responsible party and had a family member listed as his emergency contact person. R78 had signed the facility's admission contract and the consent forms for treatment with his full signature. R78's family member's contact information was listed on the face sheet. R78 was discharged home on 8/15/22 (the last day of Medicare coverage). There were no progress notes to indicate that R78 or his family member had been given a 48 hour notice regarding his Medicare non-coverage date. A progress note on 8/15/22 at 3:29 PM read, the resident has been discharged as of now.
According to R78's NOMNC form the last day of his Medicare coverage was 8/15/22. The form was dated 8/9/22 and had an 'X' where R78 should have signed that he received this information. There was an X to indicate R78 did not want to appeal the process. The area of the NOMNC form that included family member information was blank. There was no documentation to indicate that R78's family member was made aware or included in the notification of changes in R78's Medicare coverage or the appeal process.
On 11/3/22 at 11:06 AM during an interview with the Business Office Manager (BOM) E she could not explain why there was just an X on R78's NOMNC form to indicate R78 had been made aware of the Medicare changes and appeal process. BOM E acknowledged that R78 had signed his name on all his other forms while at the facility. BOM E confirmed that she did not notify the family member to assist R78 with making the decision to be discharged or appeal. BOM E said, I don't document in the resident's medical record. I don't have access. I just issue the NOMNC forms to them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy for one (R#14) of 28 residents reviewe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy for one (R#14) of 28 residents reviewed for privacy, resulting in unnecessary exposure of the resident's body and potential for embarrassment, loss of body image and loss of dignity.
Findings include:
On 11/1/22 at 8:50 A.M. R14 was observed in bed nude with multiple positioning devices not placed beneath any of the resident's body parts. A small square cloth covered a portion of the residents indwelling catheter (tube inserted into the penis to the bladder) exposing the residents' genitals. R14's privacy curtain was pulled back against the wall and the resident's door was left open. R14's entire contracted body was visible from the hallway as staff transported residents to the Therapy Department down the hall from the resident's room.
At 9:00 A.M., Certified Nurse Aide (CNA) M was queried concerning the resident's body being exposed from the hallway and the residents' roommate who consistently sat at the bottom of his bed watching television. CNA M stated, R14 privacy curtain should be pulled at least ¾ the length of the bed and the resident door was to be halfway closed to allow privacy. During the observation R14 was interviewed concerning his preference for being nude and being exposed to staff, residents, and visitors. R14 stated, Staff was supposed to pull the privacy curtain to allow privacy but sometimes it was not done.
On 11/2/22 at 9:10 A.M., 11:20 A.M., and 3:00 P.M., R14 was observed nude, and the resident's door and privacy curtain not pulled or positioned to allow privacy.
On 11/3/22 at 10:30 A.M. during a record review with Nurse J it was acknowledged R14 did not have a care plan addressing his preference to be nude or use limited amount of clothing's. A care plan was later developed and implemented after the interview on 11/3/22, when the issue of personal privacy and dignity was discussed with Nurse J.
Nurse B was made aware of the observations that had been made of R14 and was asked, about the lack of privacy provided for the resident. Nurse B stated R14 should be provided privacy to maintain his dignity, to the extent possible.
On 11/3/2022 at 11:10 A.M. review of the admission Record for R14 revealed the resident was admitted to the facility on [DATE], with diagnoses that included: Quadriplegia, right and left contractures of the shoulder's elbows, knees, and hands, neuromuscular dysfunction of the bladder, multiple sclerosis, sacral pressure ulcers, and soft tissue disorder.
The Minimum Data Set (MDS) dated [DATE], indicated R14 was moderately impaired in cognitive skills for decision-making and was totally dependent on staff for Activities of Daily Living (ADL's) with one-person physical assist.
On 11/4/2022 a review of the facility's revised policy dated 12/20 Titled: Promoting/Maintaining Resident Dignity stated, . 12. Staff should maintain resident privacy
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have appropriate documentation to support a transfer to another fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have appropriate documentation to support a transfer to another facility and evidence of communication to the receiving facility for one (R70) of three residents reviewed for transfers and discharges.
Findings include:
According to R70's Electronic Medical Record (EMR) he admitted to the facility on [DATE] with multiple diagnoses that included history of a stroke and dementia. On 8/26/22 the resident was discharged . There were no discharge notes, progress notes or assessments to explain where or why the resident was transferred out of the facility.
On 11/02/22 at 1:22 PM the Director of Nursing (DON) said R70 was transferred to another facility, where he originally resided prior to hospitalization. The hospital had accidentally discharged R70 to this facility which has a similar name. R70 was then transferred to his original facility after we discovered the error. The DON acknowledged there were no progress notes, transfer summary or additional information that should have been included in R70's EMR to indicate the reason for transfer.
According to the facility's policy Transfer and Discharge implemented on 10/21;
It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.
Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another
certified facility when the resident expects to return to the original facility.
Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another
certified facility or other location in the community, when return to the original facility is not expected .
6. Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated.
a. Document the reasons for the transfer or discharge in the resident's medical record, and in the case
of necessity for the resident's welfare and the resident's needs cannot be met in the facility,
document the specific resident needs that cannot be met, facility attempts to meet the resident
needs, and the service available at the receiving facility to meet the needs. Document any danger
to the health or safety of the resident or other individuals that failure to transfer or discharge would
pose.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% for two (R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% for two (R49 and R53) of five residents reviewed for medication administration, resulting in a 7.41% medication error rate and the potential for side effects and inaccurate dose administration.
Findings include:
R53
In a medication pass observation on 11/02/22 at 9:09 AM, with Licensed Practical Nurse (LPN) K, the nurse was observed to administer 1 puff of Combivent 18-103 milligrams (mg) inhaler to R53.
Upon medication reconciliation on 11/2/22 at 9:25 AM, with the November 2022 Medication Administration Record (MAR), and the current physician's orders documented, Combivent 18-103 milligrams (mg) 2 puffs 4 x day. At 9:49 AM, when asked about the inhaler dosing, LPN K stated, I see the order is for 2 puffs and I only gave one.
Record review revealed R53 was admitted into the facility on 8/26/22 with diagnoses which included, nontraumatic intracerebral hemorrhage, kidney disease and alcohol abuse. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was moderately impaired.
R49
In a medication pass observation on 11/02/22 at 11:24 AM, with LPN J, the nurse was observed preparing to administer insulin via insulin pen to R49. During the preparation LPN J applied the needle hub to the end of the insulin pen. The nurse then primed the insulin pen with 2 units of insulin. After priming the insulin pen, Nurse J removed the needle hub, discarded it and then applied a new needle hub. After applying the new needle hub, dialed the insulin pen to 8 units, without first priming new the hub with 2 units. Nurse J then administed the insulin to R49.
During an interview on 11/02/22 at 11:52 AM, LPN J stated, I thought when I took the cap off, I contaminated the needle, that's why I changed it. I didn't reprime, because I had already primed the first needle hub. I don't normally do that.
Record review revealed R49 was admitted into the facility on 6/16/22 with diagnoses which included, Human Immunodeficiency Virus (HIV), high blood sugars, alcohol abuse and heart failure. The quarterly MDS assessment dated [DATE] indicated the resident's cognition was moderately impaired.
Review of the physician's orders documented, NovoLog Flex Pen (insulin) Solution Pen-injector 100 UNIT/milliter (ML) (Insulin Aspart) Inject subcutaneously before meals and at bedtime for Hyperglycemia
AND Inject 15 unit subcutaneously with meals for high blood sugars to be given in addition to sliding scale insulin (SSC).
During an interview on 11/3/22 at 1:45 PM, the Director of Nursing (DON) reported being aware of the medication errors and stated having to provide inservices the nursing staff on medication administration.
Review of the manufactures' A guide using your NovoLog FlexPen dated 5/2016 documented, .prime your pen with the needle hub. Turn the dose selector to select 2 units. Press and hold the dose.
Review of the facility's policy titled Medication Preperation and General Guideline dated 6/2019 documented, . 6). If a dose of regularly scheduled medication is withheld, refused, or given at a time other than the scheduled time (e.g., a starter dose of an antibiotic is needed), the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. If an EMR is used, documentation of the dose not administered is completed as instructed by the procedures for use of the EMR system. An explanatory note is entered on the reverse side of the record. If two consecutive doses of a vital medication are withheld or refused, the physician is notified; a nurse documents the notification and the physician's response.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Michigan facilities.
- • 42% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 27 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Mission Point Nursing & Physical Rehabilitation Ce's CMS Rating?
CMS assigns Mission Point Nursing & Physical Rehabilitation Ce an overall rating of 3 out of 5 stars, which is considered average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Mission Point Nursing & Physical Rehabilitation Ce Staffed?
CMS rates Mission Point Nursing & Physical Rehabilitation Ce's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 42%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mission Point Nursing & Physical Rehabilitation Ce?
State health inspectors documented 27 deficiencies at Mission Point Nursing & Physical Rehabilitation Ce during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 25 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mission Point Nursing & Physical Rehabilitation Ce?
Mission Point Nursing & Physical Rehabilitation Ce is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MISSION POINT HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 129 certified beds and approximately 83 residents (about 64% occupancy), it is a mid-sized facility located in Detroit, Michigan.
How Does Mission Point Nursing & Physical Rehabilitation Ce Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Mission Point Nursing & Physical Rehabilitation Ce's overall rating (3 stars) is below the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Mission Point Nursing & Physical Rehabilitation Ce?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Mission Point Nursing & Physical Rehabilitation Ce Safe?
Based on CMS inspection data, Mission Point Nursing & Physical Rehabilitation Ce has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mission Point Nursing & Physical Rehabilitation Ce Stick Around?
Mission Point Nursing & Physical Rehabilitation Ce has a staff turnover rate of 42%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mission Point Nursing & Physical Rehabilitation Ce Ever Fined?
Mission Point Nursing & Physical Rehabilitation Ce has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Mission Point Nursing & Physical Rehabilitation Ce on Any Federal Watch List?
Mission Point Nursing & Physical Rehabilitation Ce is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.