Tradewater Pointe

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF810Mar 27, 2026

  Based on observation, interview, and review of facility policy, it was determined the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for one of 15 sampled residents (Resident (R) 31).The findings include:Review of the facility policy titled, Concord Health Systems, 03/31/2020, revealed nursing personnel will serve resident trays, checking the information on tray cards with the items on the trays prior to serving, and will help residents who require assistance with eating.Review of the Resident Face Sheet for R31 revealed the facility admitted the resident to the facility on [DATE], with diagnoses to include: chronic obstructive… […]

• No harm, potential for more than minimal, isolatedF609Jan 24, 2025

  Based on interview, record review, and review of facility policy, the facility failed to ensure an allegation of suspected abuse was reported in accordance with S42 CFR 483.12 (c)(1), for 1 of 12 sampled residents, (Resident (R)45). In interview, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) stated they reported to facility leadership an allegation of sexual abuse involving R44 and R45 in mid-December, 2024. However, per the facility's report, the abuse incident allegedly occurred on 12/31/2024, approximately 17 days after the nurses reporting the allegation. […]

• No harm, potential for more than minimal, isolatedF641Jan 24, 2025

  Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1, the facility failed to ensure Minimum Data Set (MDS) Assessments accurately reflected the resident status for 3 of 12 sampled residents. (Residents (R)43, 31, and 13). Record review revealed R13, R31, and R43 did not have MDS Discharge Assessments completed as required upon being discharged from the facility. The findings include: Review of the CMS RAI 3.0 User's Manual Version 1.19.1, Chapter 2: Assessments for the RAI, revealed discharge assessments must be completed when a resident was discharged from the facility. 1. […]

• No harm, potential for more than minimal, isolatedF656Jan 24, 2025

  Based on observation, interview, record review, and review of facility policy, the facility failed to develop and implement a comprehensive care plan for 2 of 12 sampled residents, (Residents (R)30, and 45). Record review revealed R30 was care planned to have both a bed and chair alarm in place; however, observation on 01/23/2025 at 10:58 AM, revealed the chair and bed alarms were not visualized as in use. Additionally, record review revealed R45 was care planned for having difficulty finding her room and a name plate with a picture with a picture of her favorite animal was to be placed outside her room to make it easier for her to find her room consistently. […]

• No harm, potential for more than minimal, isolatedF761Jan 24, 2025

  Based on observation, interview, and review of facility policy, the facility failed to store drugs in accordance with currently accepted professional practices for 1 of 2 medication carts audited out of a total of 2 medication carts and 1 of 1 audited medication rooms. Observation of the East Hall medication cart revealed 12 insulin pens not properly labeled for 8 of 15 residents. (Residents (R)32 32, 36, 17, 23, 15, 20, 35, and 5). Observation of the East Hall medication room revealed a vial of Tubersol solution (an injectable medication used to test for tuberculosis) not properly stored in the medication refrigerator. The findings include: Review of the facility policy titled, Medication Storage, revised 08/18/2017, revealed Medications. […]