Inspection Reports for
Rock Point Nursing Center

The facility was found deficient in maintaining a safe and homelike environment, failed to implement gradual dose reductions for psychotropic medications for three residents, had a medication error rate exceeding 5% due to improper insulin pen administration, and failed to implement Enhanced Barrier Precautions during tube feeding and incontinent care for one resident.

The facility was found deficient in maintaining a safe, clean, and homelike environment, managing psychotropic drug use and gradual dose reductions, maintaining medication error rates below 5%, and implementing infection prevention and control measures. Deficiencies included environmental hazards, failure to document gradual dose reductions, medication errors, and lapses in infection control practices.

The facility failed to maintain sprinkler heads free of debris, specifically three sprinkler heads in the kitchen were loaded with grease and debris. The sprinkler system did not meet NFPA requirements for maintenance, testing, and inspection.

The facility was found deficient in multiple areas including resident rights, safe environment, professional standards, ADL care, quality of care, and pest control. Several residents did not receive care consistent with their needs and physician orders, and environmental issues such as pest infestations and maintenance deficiencies were noted.

The facility failed to maintain exit devices in a means of egress readily accessible at all times, specifically locked gates with deadbolt locks without proper rapid removal provisions. No deficiencies were cited from the Emergency Preparedness survey portion.

The facility was found deficient in multiple areas including failure to provide dignified care during meals, inadequate maintenance of a safe and clean environment, failure to follow physician orders, inadequate assistance with activities of daily living such as showering, insufficient supervision during smoking, and ineffective pest control measures.

The facility was found deficient in multiple areas including resident rights and confidentiality, comprehensive care planning, pharmacy services and medication management, dialysis care, and immunization documentation. Several residents were affected by these deficiencies, and the facility census was consistently reported as 54 during the survey.

The facility failed to provide a smooth, hard surface path to the public way from two exit discharge areas and did not maintain kitchen exit corridors and smoke barrier doors in proper working order. Several fire safety deficiencies were identified related to discharge from exits, cooking facilities, and smoke barrier doors.

The facility was found deficient in multiple areas including failure to protect resident confidentiality, incomplete and inaccurate care plans, inadequate assessment and documentation of dialysis AV fistula and pommel cushion use, improper narcotic count documentation, failure of the pharmacist to ensure appropriate diagnoses for antipsychotic medication use, and failure to provide pneumococcal vaccine education and documentation.

The facility was found deficient in multiple areas including resident rights, self-determination, safe environment, comprehensive care plans, infection control, medication management, and quality of care. Several residents were observed to have unmet needs and the facility failed to provide adequate care and services as required.

The facility failed to maintain emergency lighting and had combustible decorations in resident rooms, which posed potential fire hazards. The emergency preparedness portion of the survey did not result in any deficiencies.

The facility failed to notify the resident and the resident's representative in writing about a facility-initiated transfer to the hospital and failed to notify the Office of the State Long-Term Care Ombudsman. The facility also failed to provide written notice regarding the bed-hold policy to a resident or their representative at the time of transfer or admission.

The facility failed to maintain the fire sprinkler system clearance due to a stack of pillows, improperly disposed combustible materials in smoking areas, and inadequate storage and labeling of oxygen cylinders. These deficiencies potentially affected all residents and staff.