North Pointe Care Center

In the surveyor’s words

From the most serious findings on record at North Pointe Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 24, 2026

  Based on observation, interview and record review, the facility failed to protect one of three residents sampled for abuse investigation (Resident 2) from physical abuse, when Resident 1 pushed Resident 2 and Resident 2 landed on the floor face down, sustaining a fracture to her right upper arm (humerus) and a right hip (femoral) fracture. This failure resulted in Resident 2 experiencing physical pain and had a significant decline in functional status from being totally independent, to requiring maximum assist (where staff provide most of the activities for the resident) for mobility and with daily activities.A review of the admission Record printed on 7/24/26 indicated the facility admitted Resident 1 on 6/11/26 with multiple diagnoses which included Alzheimer's disease (an irreversible,… […]

• Actual harm, isolatedF684Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to provide the necessary care and services and implement measures for the prevention of pressure injuries (painful wounds caused as a result of prolonged pressure or friction) for two of 37 sampled resident (Resident 4 and Resident 32), who were at risk for skin injuries when, Resident 4 obtained a skin tear (a traumatic wound of the top layer of skin) from the use of bolster (part of a mattress cover with raised foam edges on each side of the bed to prevent resident from rolling out of bed), did not implement interventions addressing use of bolster, did not document accurate assessments of the wound every shift as indicated by resident's care plan; and Failed to ensure pressure ulcer risk factors were thoroughly… […]

• Actual harm, isolatedF600Sep 26, 2025

  Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by Resident 2 for one of three sampled residents (Resident 1) when Resident 2, who had a history of verbal threats struck Resident 1 in the face.This failure resulted in Resident 2 striking Resident 1 causing lacerations to Resident 1's eyebrow, nose and cheek, caused pain, and had the potential for Resident 1 to experience emotional distress.Findings:A review of the admission Record indicated the facility admitted Resident 1 in May 2025 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities).A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/11/25… […]

• Actual harm, isolatedF600Jul 10, 2024

  Based on observation, interview, and record review, the facility failed to protect 2 of 6 sampled residents (Resident 2 and Resident 4) from abuse when: 1. Resident 1 pulled Resident 2's walker causing him to fall, and 2. Resident 3 punched Resident 4 on the face during an altercation. These failures resulted in Resident 2 sustaining a right intertrochanteric fracture (broken hip bone) and underwent hip arthroplasty (a surgery to replace the broken hip bone with an artificial implant) and Resident 4 had the potential to experience physical injury and emotional distress. […]

• Actual harm, isolatedF600Apr 2, 2021

  Based on interview, and record review, the facility failed to protect one resident (Resident 1) in a census of 139 from physical abuse when the facility assigned Resident 1, known to have wandering behaviors, to a room with a resident (Resident 2) known to have aggressive and territorial behaviors. This failure resulted in Resident 2 physically attacking her roommate, Resident 1, in their room resulting in a physical injury. Findings: Resident 2 was admitted to the facility in July 2017 with diagnoses, which included [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves), dementia (impairment in memory, communication, and thinking), and persistent mood disorders (a mental health problem that primarily affects a person's emotional state). […]