Mission Point Nursing & Physical Rehabilitation Ce

In the surveyor’s words

From the most serious findings on record at Mission Point Nursing & Physical Rehabilitation Ce, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 17, 2024

  This citation pertains to MI00145581. Based on interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 2 residents (Resident #305) reviewed for elopements, resulting in an Immediate Jeopardy when on 6/13/2024 at approximately 8:34 PM, Resident #305, who was cognitively impaired exited the facility by facility staff when he was mistaken for a visitor and traveled on foot along a busy road with a speed limit of 40 miles per hour looking for his sister. Resident #305 was found by community members who returned him to facility staff who were searching for him and they brought him back to the facility. […]

• Immediate jeopardy, isolatedF760Jul 17, 2024

  This citation pertains to Intake MI00145186 Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 1 resident (R404) reviewed for medication administration resulting in an Immediate Jeopardy when, beginning on 5/23/2024 at approximately 7:46 AM, R404 was administered another residents medications and was found unresponsive. Resident #404 was hospitalized in the ICU (Intensive Care Unit - provides care and life support for acutely ill/injured patients) on BiPAP (Bilevel Positive Airway Pressure - a device that helps with breathing) with a Narcan drip (a medication used to treat an opioid overdose) and the likelihood of further life-threatening deterioration in his medical condition. […]

• Actual harm, isolatedF658Jul 17, 2024

  This citation pertains to MI00145186 Based on observation, interview, and record review the facility failed to follow professional standards of practice for nursing for 1 of 18 residents (R404) reviewed for significant medication errors resulting in R404 receiving another resident's medications including opioids, experienced respiratory failure, and sent to the hospital for life-sustaining treatment. Findings include: R404 According to the Minimum Data Set (MDS), dated [DATE], R404 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status). […]

• Actual harm, isolatedF684Jul 17, 2024

  This citation pertains to intake: MI00145580 Based on record review and interview, the facility failed to ensure residents recieved care in accordance with residents needs in 2 of 18 residents (Resident #27 and Resident #406) review for quality of care, resulting in Resident #27 not receiving appropriate assessment and treatment for a injury of unknown origin, and Resident #406 not attending follow up appts with surgeon following spinal fusion surgery. Findings include: Resident #27: Review of an Admission Record revealed Resident #27 was a male with pertinent diagnoses which included dementia, abnormal posture (added 5/25/24), pain in right hip (added 6/25/24), pain in right knee (added 6/18/24), stroke, polyneuropathy (damage/disease affecting peripheral nerves on both sides of the… […]

• No harm, potential for more than minimal, widespreadF804Jul 23, 2026

  Based on observation, interview, and record review the facility failed to ensure food served was palatable and served at a safe and appetizing temperature for 3 of 54 residents (R7, R48, R14) reviewed for palatable food, resulting in the potential for meal dissatisfaction for all residents in the facility. Findings include: On 7/20/26 at 12:10 PM, [NAME] M stated that they switched the menu to tuna sandwiches instead of the tuna melt listed on the menu because they ran out of cheese slices. On 7/20/26 at 12:22 PM, the plate warmer was observed off and not warm to the touch. [NAME] M stated that the plate warmer does not work. […]