Inspection Reports for North Pointe Health Rehabilitation Services

The State Agency conducted two complaint investigations at the facility on 1/28/26 through 1/29/26 related to neglect, physical environment, nursing services, infection control, and resident falls.

The survey determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

Two complaint investigations (CI MS #2692819 and CI MS #2693273) were conducted. CI MS #2692819 investigated neglect, physical environment, nursing services, and infection control. CI MS #2693273 investigated resident falls. No deficiencies were found.

The State Agency conducted two complaint investigations at the facility on January 28-29, 2026, related to neglect, physical environment, nursing services, infection control, and resident falls.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Two complaint investigations (CI MS #2692819 and CI MS #2693273) were conducted. CI MS #2692819 investigated neglect, physical environment, nursing services, and infection control. CI MS #2693273 investigated resident falls. Both complaints were found to have no deficiencies.

The State Agency conducted a Complaint Investigation (MS #2628563) related to resident rights and quality of care at the facility from 10/27/25 through 10/28/25.

The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the complaint investigation.

Complaint Investigation MS #2628563 was related to resident rights and quality of care and was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #2628563, related to resident rights and quality of care at the facility from 10/27/25 through 10/28/25.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #2628563 related to resident rights and quality of care; no deficiencies were cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-06-19 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2025-07-26.

The State Agency conducted an Annual Survey at the facility from 6/16/2025 to 6/19/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with residents' rights, activity program implementation, safe food handling procedures, and infection control standards. Specific deficiencies included failure to identify and document use of a physical restraint, lack of a consistent resident-centered activity program, dietary staff not wearing hair restraints, and failure to follow enhanced barrier precautions during care.

The State Agency conducted an annual recertification survey at the facility from 6/16/25 to 6/19/25 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple requirements including residents' rights to be free from physical restraints, accuracy of assessments, comprehensive care planning, resident activities, food safety, and infection prevention and control.

The State Agency conducted a desk review on 08/05/25 of information related to the annual survey completed on 06/19/25 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 07/26/25.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements and no deficiencies were cited during the survey.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no deficiencies were cited during the inspection.

The State Agency conducted an annual recertification survey at the facility from 01/08/2024 through 01/10/2024 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance due to failure to ensure a hazardous cleaning agent (Super Sani-Cloth Germicidal Disposable Wipes) was not left unattended in an accessible hallway, posing a potential risk to residents. The facility implemented corrective actions including removal of wipes from accessible areas, staff in-service, and ongoing monitoring.

The State Agency conducted an annual licensure survey at the facility from 01/08/24 through 01/10/24 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.

The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and no deficiencies were cited.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited.

The State Agency conducted a desk review of information related to the annual survey completed on 01/10/24 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the agency recommended the facility be placed back in compliance effective 02/07/24.

The State Agency conducted a desk review related to the annual survey completed on 01/10/24 to assess the facility's compliance with Medicare and Medicaid requirements.

The facility provided information confirming corrective measures were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 02/07/24.

The State Agency conducted an annual recertification survey at the facility from 01/08/2024 through 01/10/2024 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance due to failure to ensure hazardous cleaning agents were not left unattended in areas accessible to residents, posing a potential safety hazard. Specifically, Sani-Cloth Germicidal Disposable Wipes were found accessible in hallways, contrary to facility policy requiring locked storage.

The State Agency conducted an annual licensure survey at the facility from 01/08/24 through 01/10/24 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.

The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and no deficiencies were cited during the survey.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete COVID-19 information to the NHSN during a seven-day period from 10/02/2023 to 10/08/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.

The State Agency conducted a Complaint Investigation (CI), MS #22035, at the facility related to a reported incident of verbal abuse.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #22035 was related to a facility reported incident of verbal abuse. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation at the facility on 7/18/23 related to a facility reported incident of verbal abuse.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #22035 was related to verbal abuse. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a complaint investigation related to a facility reported incident of verbal abuse.

The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.

Complaint Investigation (CI), MS #22035, related to verbal abuse; no deficiencies cited.

The State Agency conducted a Complaint Investigation (CI), MS #18979, at the facility on 9/26/22 through 9/27/22 related to food, responsible party notification, and an injury of unknown origin.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. The complaint was not substantiated and no deficiencies were cited.

Complaint MS #18979 related to food, responsible party notification, and an injury of unknown origin was investigated and not substantiated.

The State Agency conducted a Complaint Investigation (CI), MS #18979, at the facility on 9/26/22 through 9/27/22.

The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint related to food, responsible party notification, and an injury of unknown origin was not substantiated. No deficiencies were cited.

Complaint MS #18979 was investigated and not substantiated.

The State Agency conducted a follow-up/revisit survey on 09/21/21 for an annual survey that was conducted from 08/17/21 through 08/21/21.

The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid.

The State Agency conducted a follow-up/revisit survey on 9/21/21 for an annual survey that was conducted from 8/17/21 through 8/21/21.

The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid.

The State Agency conducted a follow-up/revisit survey on 9/21/21 for an annual survey that was conducted from 8/17/21 through 8/21/21.

The State Agency determined the facility was found to be in compliance with the requirements for participation in Medicare and Medicaid.

The inspection was an annual recertification survey conducted from 8/17/21 to 8/20/21 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found to be in compliance with all applicable standards and no deficiencies were cited during the survey.

The State Survey Agency conducted an annual survey from 8/17/21 through 8/21/21 to determine compliance with Medicare and Medicaid Requirements for participation.

The facility was found non-compliant with food safety requirements, specifically failing to ensure food was distributed and secured under professional standards, including failure to cover, date, and label food items in refrigerators and freezers, and failure to monitor and record food and storage temperatures properly.

The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.

A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with infection control regulations and no deficiencies were cited during the survey.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/11/21 to assess compliance with emergency preparedness regulations.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

The State Agency conducted a complaint investigation (CI MS #16860) on 07/07/2020 regarding the facility's failure to allow a resident/family the right to manage their financial affairs.

The facility was found not in substantial compliance with Medicare and Medicaid participation requirements due to failure to allow Resident #1 and family to manage financial affairs. The resident's stimulus check was deposited into the facility's trust account without notifying the family, and the facility controlled the funds without prior family consent.

The complaint was substantiated for failure to allow the resident/family the right to manage financial affairs. The complaint was not substantiated for Quality of Care.

The State Agency conducted a complaint investigation (CI MS #16860) on 07/07/2020 regarding the facility's failure to allow the resident/family the right to manage their financial affairs.

The facility was found not in substantial compliance with Mississippi Regulations for the Minimum Standards for Institutions for the Aged or Infirm due to failure to allow Resident #1 and family to manage financial affairs. The resident's stimulus check was deposited into the facility's trust account without notifying the family, who were not informed unless they inquired. The facility reimbursed families for purchases made on behalf of the resident from the trust account.

The complaint was substantiated for the facility's failure to allow the resident/family the right to manage their financial affairs (state statute M500). The complaint regarding Quality of Care was not substantiated.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

The State Agency conducted an annual recertification survey to assess compliance with State Licensure requirements.

The facility was found to be in compliance with State Licensure requirements and no deficiencies were cited during the survey.

A standard survey was conducted at North Pointe Health and Rehabilitation from March 25, 2019 through March 28, 2019 to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. No deficiencies were cited in the Life Safety Code survey or the Emergency Preparedness survey.