Mcnaughten Pointe Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Mcnaughten Pointe Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF697Mar 15, 2024

  Based on medical record review, review of hospital records, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to provide timely and effective pain management as well as adequately monitor resident pain. Actual harm occurred on 01/11/24 when Resident #65 fell , complained of pain to her right ankle, was not provided effective pain management, and was subsequently unable to get out of bed on 01/12/24 due to increased pain associated with the fall. The resident was transferred to the hospital on 01/12/24 at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. The resident required Oxycodone-Acetaminophen for pain. […]

• Actual harm, isolatedF883Mar 15, 2024

  Based on medical record review, review of hospital records, staff and resident interview, review of facility policy, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to appropriately obtain consent and timely administer a flu and pneumococcal immunizations. Actual harm occurred on 02/29/24, when Resident #104 was diagnosed with pneumonia and was hospitalized for ten days for treatment including intravenous antibiotic therapy. The resident's representative gave permission for the resident to receive the pneumococcal vaccination on 02/01/24 (admission); however, the facility failed to administer the vaccination to the resident. This affected two (Residents #89 and #104) of five residents reviewed for immunizations. The facility census was 117. […]

• Actual harm, isolatedF684Mar 3, 2021

  Based on closed medical record review, staff interview and review of the facility Skin Assessment policy, the facility failed to ensure accurate and on-going skin assessments (monitoring) were completed to timely identify and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 02/01/21 when Resident #120, who was cognitively impaired and required extensive assistance to total dependence on staff for activities of daily living was found to have eight new areas of non-pressure related skin impairment upon transfer back to her previous nursing home residence which had not been identified by the facility. The resident was transferred from the facility without evidence of a comprehensive skin assessment being completed at the time of discharge. […]

• No harm, potential for more than minimal, widespreadF880Mar 30, 2022

  Based on observation, medical record review, staff interview, and facility policy and procedure, the facility failed to maintain infection control, related to personal protective equipment (PPE) use, proper hand hygiene, and glove use. This affected two residents (Resident #67 and Resident #220) with the potential to affect all residents in the facility. Findings include: 1. Review of the medical record for Resident #220 revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] revealed Resident #220 was alert and oriented, but confused, and her lungs were clear with a regular respiratory rate. […]

• No harm, potential for more than minimal, patternF761Jun 23, 2026

  Based on medical record reviews, observation, and staff interview, the facility failed to ensure residents' medications were not prepared and removed from the original packaging prior to time of medication administration. This affected eight (Residents #3, #4, #5, #6, #7, #8, #9, and #11) of the eight residents reviewed for medication administration. The facility census was 122. Findings include:Observation completed on 06/23/26 from 3:51 A.M. through 4:11 A.M. of five medication carts revealed medication for eight residents (#3, #4, #5, #6, #7, #8, #9, and #11) residing on the East unit had been pulled from their original package provided by the pharmacy and placed in a medication cups for administration at a later time. An interview on 06/23/26 at 3:58 A.M. […]