Promontory Point Rehabilitation

In the surveyor’s words

From the most serious findings on record at Promontory Point Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578May 28, 2026

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 9 of 12 residents (Resident #2, # 3, #17, #29, #37, #52, #60, #61 and #66) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. […]

• No harm, potential for more than minimal, patternF880May 28, 2026

  Based on observation, policy review, manufacture's manual review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment for 2 of 2 residents (#57 and #66 ) observed for respiratory equipment use and clean/sanitary laundry rooms. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Nebulizer Therapy policy revision date [DATE], directed staff to clean the nebulizer after each use. […]

• No harm, potential for more than minimal, patternF578Mar 8, 2024

  Based on policy review, record review, and resident, and staff interview, it was determined the facility failed to ensure a residents' advance directive or POST were obtained and documented in their record. This was true for 4 of 12 residents (Resident #1, 130, #7, and #182) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes regarding their advanced care plans were not followed or documented. […]

• No harm, potential for more than minimal, patternF655Mar 8, 2024

  Based on record review, policy review and resident staff interview, it was determined the facility failed to ensure a baseline care plan was reviewed and provided to residents' and their representative. This was true for 5 of 12 residents (#7, #16, #130, #181, and #184) whose records were reviewed. This failure placed residents at risk of not having their goals for care and services met. Findings include: A facility policy titled, Baseline Care Plan, undated, documented the facility would develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care that met professional standards of quality care. […]

• No harm, potential for more than minimal, patternF880Mar 8, 2024

  Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment. This was true for 2 of 4 residents (#116 and #133) observed for infection control. This failure created the potential for harm by placing residents at risk for cross-contamination and infection. Findings include: 1. Resident #133 was admitted on [DATE], with multiple diagnoses including aftercare following total knee replacement. The facility's Personal Protective Equipment Policy (PPE), dated, 7/8/23, stated personal protective equipment appropriate to specific task requirements would be utilized per CDC guidelines. […]