Nans Pointe Rehabilitation and Nursing

In the surveyor’s words

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

• Actual harm, isolatedF697Jul 12, 2022

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to provide pain management to include scheduled narcotic analgesics ([MEDICATION(S)] HCl 2 milligrams (mg) and [MEDICATION(S)] 25 mg) which resulted in frequent unnecessary and often excruciating pain, constituting harm for 1 of 47 residents (Resident #267), in the survey sample The findings included: The facility staff failed to provide scheduled around-the-clock pain medications to Resident #267, by failing to obtain and administer the prescribed narcotic analgesics ([MEDICATION(S)] HCl 2 milligrams (mg) and [MEDICATION(S)] 25 mg), they also failed to institute their protocol for obtaining controlled medication from their medication storage system… […]

• No harm, potential for more than minimal, widespreadF804Jul 12, 2022

  Based on observations and staff interviews, the facility staff failed to provide food that was prepared by methods that conserved the nutritive flavor and appearance. The findings included: During the kitchen observations at 11:07 a.m. on 07/07/22 during the lunch meal preparation, the facility staff was noted to serve mixed vegetables, lasagna, garlic bread, strawberry short cake and several beverages. The lasagna was the main entree for the lunch meal. During the temperature checks and observations made of the lasagna, the appearance of the lasagna was noted to be burned (blackened) and crusted in appearance. The texture of the lasagna was rubbery and mushy. This surveyor tasted the lasagna and it was not pleasing. The lasagna had a burned taste. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2022

  Based on observations and staff interview, the facility staff failed to store and served food under sanitary conditions. The findings included: During the kitchen observations at 11:07 a.m. on 07/07/22 the left wall next to the eight burner stove and two door oven, was noted to copious amounts of burnt grease and food particles. Behind the stove was burned food particles and food crumbs. Food and debris was observed behind the standing two part oven. The wall next to the eight burner stove was observed to have a hole that measured an estimated 10 inches long and 3 inches wide. Rust was noted on the electrical sockets in front of the the eight burner stove. The wall behind the ice machine was observed to have an estimated 8 inch by 3 inch hole. The plaster was observed to be coming off. […]

• No harm, potential for more than minimal, widespreadF814Jul 12, 2022

  Based on observation and staff interview the facility staff failed to maintain outside refuse area free of debris and trash. The findings included: During the outside observation of the trash dumpster area at 1:15 P.M. on 07/07/22, the area was observed to have trash and debris on the ground around the two dumpster area. The Dietary Manager stated, housekeeping and maintenance were responsible for maintaining the areas.

• No harm, potential for more than minimal, patternF628Jul 10, 2026

  Based on record review, interviews, and policy review, the facility failed to ensure a signed bed hold were included in the transfer to the hospital for three of four residents (Resident (R) 44, R12, and R73) reviewed for hospitalization out of 24 sample residents. This failure had the potential of not relaying pertinent medical and demographic information to the receiving hospital. Findings include: 1.) Review of R44'sadmission Record located in the electronic medical record (EMR) under the Profile tab revealed R44 was initially admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of R44's Progress Notes, dated 06/29/26, revealed R44 had been sent to the emergency room after a syncopal episode while in rehabilitation. […]