Zarrow Pointe

In the surveyor’s words

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

• Actual harm, isolatedF656May 19, 2025

  Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed to include the amount of assistance needed for incontinent care and bed mobility for 1 (#1) of 3 sampled residents whose care plans were reviewed. The DON identified 56 residents resided in the facility. Findings: On 05/08/25 at 2:30 p.m., Resident #1 was observed in bed. Signage was observed on the wall by the resident's bed that showed the resident required the assistance of two staff for all personal care while in bed. On 05/12/25 at 2:04 p.m., CMA #1 and CNA #2 were observed to provide incontinent care to Resident #1. […]

• Actual harm, isolatedF689May 19, 2025

  Based on observation, record review, and interview, the facility failed to ensure residents were free from falls during incontinent care for 1 (#1) of 3 sampled residents who were reviewed for falls. The DON identified 18 residents who required the assistance of two staff during incontinent care. Findings: On 05/08/25 at 2:30 p.m., Resident #1 was observed in bed. The bed was observed to be low with the left side of the bed against the wall and a fall mat was observed to be on the floor on the right side of the bed. Signage was observed on the wall by the resident's bed that showed the resident required the assistance of two staff for all personal care while in bed. On 05/12/25 at 2:04 p.m., CMA #1 and CNA #2 were observed to provide incontinent care to Resident #1. […]

• No harm, potential for more than minimal, patternF550Apr 5, 2024

  Based on observation, record review, and interview, the facility failed to: a. speak to a resident in a respectful manner for one (#28); and b. ensure resident clothing labels were not visible for one (#39) of three sampled residents reviewed for dignity. The DON identified a census of 58. Findings: A Quality of Life-Dignity policy, revised 08/09, read in part, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Treated with dignity .means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall speak respectfully to residents at all times .Demeaning practices and standards of care that compromise… […]

• No harm, potential for more than minimal, patternF657Apr 5, 2024

  Based on record review and interview, the facility failed to revise care plans for two (#22 and #37) of 18 sampled residents reviewed for accuracy of care plans. The DON identified a census of 58. Findings: A Care Plans, Comprehensive Person-Centered policy, dated 12/16, read in part, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #37 had diagnoses which included aftercare following surgical amputation. A progress note, dated 01/15/24, documented Resident #37 was readmitted to skilled care after a left above knee amputation had been performed on 01/11/24. […]

• No harm, potential for more than minimal, patternF689Apr 5, 2024

  Based on observation and interviews, the facility failed to ensure harmful chemicals were secured. The Administrator identified six residents that required wander guards to be worn for safety. The DON identified a census of 58. Findings: On 04/01/24 at 9:58 a.m., an observation of 1/10 of a gallon container of dish detergent, 1/10 of a 32 oz. bottle of lime and calcium remover, 1/2 full spray bottle labeled with black marker cleaner with bleach, and a full 15 oz. aerosol can of stainless steel cleaner were observed sitting on top of the dishwasher in the room which connected the two dining rooms. A one gallon container of dish detergent and a one gallon container of sanitizer on a rack that was attached to the sink were also observed in the room. […]