Allison Pointe Healthcare Center

In the surveyor’s words

From the most serious findings on record at Allison Pointe Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 3, 2023

  Based on observation, interview, and record review, the facility failed to ensure admission orders were entered into the electronic medical record accurately, timely, and that such orders were administered as ordered by the physician for a resident with type 1 diabetes resulting in the resident experiencing a change in condition that included nausea and vomiting that was not documented in the medical record (Resident B); ensure a diabetic resident's sliding scale insulin order was continued upon admission to the facility; administer a resident's pain medication as ordered (Resident D); ensure weekly wound assessments were conducted; administer insulin as ordered (Resident C); provide geri-sleeves and Prevalon boots, as ordered (Resident 11); address a resident's low blood pressure… […]

• Actual harm, isolatedF687Apr 8, 2026

  Based on interview and record review, the facility failed ensure a resident received timely foot care related to a referral for a vascular specialist and treatment for osteomyelitis, resulting in a hospitalization for intravenous antibiotics and subsequent toe removal for 1 of 3 residents reviewed for foot care. (Resident E) Findings include:The clinical record for Resident E was reviewed on 4/7/26 at 10:00 a.m. The resident's diagnosis included, but was not limited to, peripheral artery disease (circulatory condition caused by plaque buildup, narrowing arteries, and reduces blood flow to the limbs). The impaired skin integrity care plan, revised 3/31/26, indicated the resident had areas to his left fourth and fifth toes. […]

• Actual harm, isolatedF684May 26, 2022

  Based on interview and record review, the facility failed to administer residents' medications as ordered, timely address skin conditions, provide wound care as ordered, and administer treatments as ordered, resulting in debridement and delayed surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents B, F, 37, 82, 103, 229, and 233) Findings include: 1. The clinical record for Resident B was reviewed on 5/20/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility from the hospital on 3/10/22. […]

• Actual harm, isolatedF697May 26, 2022

  Based on observation, interview, and record review, the facility failed to timely administer pain medications, as ordered by the physician, resulting in severe pain and refusal of wound care due to pain, for 4 of 8 resident reviewed for pain management (Residents 33, 68, 82, and 233). Findings include: 1. The clinical record for Resident 68 was reviewed on 5/18/22 at 9:48 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed 3/16/22, indicated he was cognitively intact. He received scheduled and as needed pain medications daily and his pain made it hard for him to sleep and limited his daily activities. A care plan, revised on 4/22/22, indicated he had acute and chronic pain related to his [CONDITION(S)]. […]

• Actual harm, isolatedF695Oct 28, 2021

  Based on interview and record review, the facility failed to apply a [CONDITION(S)] (bilevel positive airway pressure) machine as ordered by the physician. This resulted in the respiratory distress and hospitalization of 1 of 3 residents reviewed for respiratory care (Resident B). Findings include: The clinical record for Resident B was reviewed on 10/27/21 at 11:45 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed 7/31/12, indicated that he needed extensive assistance with personal hygiene and did not exhibit episodes of rejection of care. […]