Eagle Point Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Eagle Point Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Apr 3, 2025

  Based on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1st December 31), facility record review, and staff interviews the facility failed to submit accurate staffing data for the PBJ Staffing Data Report. The facility reported a census of 53 residents. Findings include: The PBJ report from the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Roster (nursing assignment) dated 12/28/24, identified the Minimum Data Set (MDS) nurse worked the 2-10 shift due to a call off for for the 2-10 shift. The Daily Roster dated 12/29/24, showed the Assistant Director of Nursing (ADON) worked the day shift and the MDS nurse worked the 2-10 shift due to a nurse called off for a double shift. […]

• No harm, potential for more than minimal, widespreadF880Jun 6, 2024

  Based on observation, record review, staff interview, and policy review the facility failed to specify and maintain appropriate water temperatures in order to prevent legionella growth or use appropriate personal protective equipment (PPE) when laundering contaminated items. In addition, the facility failed to use a barrier when emptying the catheter bag for 2 of 2 residents reviewed (Residents #13 and Res #32). The facility failed to utilize enhanced barrier precautions when completing wound care on 1 out 3 wound cares observed (Resident #44). The facility reported a census of 52 residents. Findings include: 1. […]

• No harm, potential for more than minimal, patternF804Apr 23, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure food served at a palatable temperature and texture. The facility reported a census of 58 residents.Findings Include:During an interview on 04/20/2026 at 10:30 AM Resident #40 stated the facility only had one choice for some meals. The resident stated he cannot stand the pork chops as they are tough. Resident #40 stated the food could use improvement, and explained food had been service cold, overcooked and chewy making it difficult to eat. Resident #40 stated he had brought up his concerns to multiple staff but it continued to be a problem. During an interview on 04/20/2026 at 11:05 AM, Resident #18 stated the food can be cold at times. […]

• No harm, potential for more than minimal, patternF584Jun 6, 2024

  Based on observation, record review, resident and staff interview, the facility failed to maintain a homelike environment for resident rooms for six out of six rooms reviewed. (Residents #5, #6, #31, #40, #45). The facility reported a census of 52 residents. Findings include: Observations of residents' rooms revealed the following: a. On 6/3/24 10:31 AM, Resident #5's bathroom door had approximately 40% of the paint missing from the bottom. Resident #5 reported the door to her bathroom looked that way since she moved in 3 years ago. In addition, the wall outside the door on the left side didn't have a baseboard. b. On 6/4/24 at 7:29 AM, Resident #40's bathroom door had splintering noted to bottom portion of the door. c. […]

• No harm, potential for more than minimal, patternF656Jun 6, 2024

  Based on observation, record review, and staff interview, the facility failed to identify resident problems and implement appropriate interventions on the Care Plans for four of four residents reviewed (Residents #13, #21, #31, and #34). The facility reported a census of 52 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #13 required substantial/maximal staff assistance with dressing and required total assistance from staff with toilet use, showers, putting on and taking off footwear. In addition, the MDS also identified Resident #13 had an indwelling catheter and colostomy. […]