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.

• Actual harm, isolatedF805Jun 23, 2026

  This citation pertains to Incident 3044880Based on interview and record review, the facility failed to ensure a snack was given in a form consistent with physician diet orders for one (R302) of four residents reviewed for therapeutic diets resulting in R302 choking on a peanut butter sandwich requiring emergency intubation and was hospitalized with extensive hypoxic ischemic brain injury [brain damage due to loss of oxygen]. Findings include:A Facility Reported Incident [FRI] was received by the State Agency [SA] on 6/9/26 that reported in part R302 ate a peanut butter and jelly sandwich, staff performed the Heimlich Maneuver and R302 was transported to the hospital.Review of the closed record revealed R302 was admitted into the facility on 2/2/23 with diagnoses that included: acute… […]

• Actual harm, isolatedF600Aug 2, 2023

  This citation pertains to Intake Number(s): MI00138552. Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for two (R804 and R805) of five residents reviewed for abuse, resulting in R804 choking R805, and other residents reported feeling scared, unsafe, and/or had nightmares after the abuse occurred (R807, R808, R809). Findings include: Review of a Facility Reported Incident (FRI) was submitted to the State Agency on 7/15/23 revealed the facility reported a physical abuse incident that occurred between R804 and R805. […]

• Actual harm, isolatedF686Oct 28, 2021

  Based on observation, interview, and record review the facility failed to ensure appropriate interventions and monitoring to prevent the worsening of a pressure wound were in place for one resident (R34) of two residents reviewed for pressure ulcers, resulting in the development of a stage four pressure ulcer [Full thickness tissue loss with exposed bone, tendon, or muscle.] to the coccyx area of R34. Findings include: On 10/26/21 at approximately 10:44 a.m., R34 was observed in their room, lying in their bed. R34 was observed to by laying on their back. No offloading of pressure to the back was observed with pillows or positioning wedges. Multiple positioning wedges were observed to be in the corner of R34's room. […]

• No harm, potential for more than minimal, widespreadF867Jul 8, 2025

  Based on observation, interview, and record review, the facility failed to implement an effective plan of action to correct identified quality deficiencies related to controlled substances (medications regulated by the government due to having a high risk of abuse and/or addiction), resulting in the continuation of deficient practices related to having an effective process to accurately account for all controlled substances for six (R704, R705, R706, R707, R709, and R710) of seven residents reviewed. This had the potential to affect all residents who resided in the facility who were prescribed controlled substances. […]

• No harm, potential for more than minimal, widespreadF812Feb 5, 2025

  Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 2/4/25 between 9:00 AM-9:30 AM, during an initial observation of the kitchen with Dietary Manager (DM) J, the following items were observed: In the Traulsen reach-in cooler, there was a pan of raw chicken stored directly on top of a box of cooked diced chicken, and raw pork stored on top of a box of corn chowder soup. […]