Center at Northridge, LLC, the

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process focussing on the resident's discharge goals for three (#76, #47 and #64) of five residents reviewed for discharge planning out of 38 sample residents. Specifically, the facility failed to for Resident #76, Resident #47 and Resident #64: -Involve the resident and the resident's representative in the discharge plan; and, -Develop discharge care plan with appropriate goals and approaches.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the safety and supervision to prevent accidents for one (#66) of three residents reviewed for falls of 38 sample residents. Specifically, the facility failed to ensure Resident #66 was safe while ambulating with therapy.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow correct portion sizes to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically the facility failed to: -Ensure food was served at proper temperatures; -Store equipment in a sanitary manner; -Sanitize equipment properly and hygienically; and, -Have a thermometer internally for the walk in refrigerator and walk in freezer.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have an effective infection control program. Specifically, the facility failed to: -Ensure staff offered hand sanitation prior to resident meals; -Perform appropriate screening, restrictions and education of visitors; and, -Ensure housekeeping staff completed proper handwashing, and disinfected appropriately during cleaning of resident rooms.

Inspectors wroteBased on observations, interviews and record review,, the facility failed to provide a meaningful program of activities for three (#285, #32 and #133) of four residents reviewed for activities out of 38 sample residents. Specifically, the facility failed to: -Ensure the facility provided consistent activity programming after 3:00 p.m. seven days a week; -Ensure Resident #285 was offered preferred activity programs in the evening and more than one program a day; -Ensure Resident #32 was offered a resident centered activity program including one-to-one social activities in her room; and, -Ensure Resident #133 was offered a resident centered activity program including independent leisure activities in her room.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide needed care and services that meet professional standards of practice for of six (#187, #384, #189, #78, #40, #61) of nine residents reviewed for quality of care of 38 sample residents. Specifically, the facility failed to: -Provide wound care treatments as ordered for Resident #384, #78, #187; -Follow blood pressure medication parameters for Resident #40, #189; -Administer an antibiotic as ordered for Resident 189; and, -Have pain medication parameters for Resident #61.

Inspectors wroteBased on interviews and observations, the facility failed to store drugs and biologicals under proper temperature controls in one of two medication storage rooms reviewed. Specifically, the facility failed to ensure: -Vaccine refrigerators maintained temperature parameters for vaccine storage; and, -Vaccine refrigerators with digital data logger thermometer.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for one (#186) of five out of 38 sample residents. Specifically, the facility failed to: -Have an accurate Colorado medical orders for scope of treatment (MOST) form uploaded in the electronic medical record (EMR) for Resident #186, the MOST form uploaded was dated [DATE] for Full cardiopulmonary resuscitation (CPR), however the physician orders in the EMR said do not resuscitate (DNR); -Obtain the medical durable power of attorney (MDPOA) signature timely for a new MOST form; and, -Date the new MOST form accurately when the MDPOA signature was obtained.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#187) out of three residents reviewed out of 38 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed timely follow-up with grievances from Resident #187.

Inspectors wroteBased on interviews and record review, the facility failed to assure that services being provided met professional standards of quality for three (#2, #71, #384) of nine residents reviewed for medication administration out of 38 sample residents. Specifically, the facility failed to document administration for Resident #2, #71 and #384 medications that were documented as being administered on the narcotic log sheets.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an environment free of accidents and hazards for two (#61 and #382) of two of 38 sample residents. Specifically, the facility failed to: -Protect Resident #61's feeding tube site resulting in the tube dislodging and requiring hospitalization on two occasions; and, -Transfer Resident #382 with two staff members as recommended by the therapy department.

Inspectors wroteBased on interviews and observations, the facility failed to provide adequate maintenance and prevention of infection at a peripherally inserted central catheter (PICC) line insertion site for one (#15) of two residents reviewed for PICC care services of 38 sample residents. Specifically, the facility failed to maintain a sterile field while performing a PICC line dressing change.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice for one (#285) of four residents reviewed for oxygen therapy out of 38 sample residents. Specifically, the facility failed to ensure: -Resident #285 had oxygen turned on while laying in bed to follow current physician orders between one to five liters per minute; and, -Physician order for oxygen was followed for Resident #285.

Inspectors wroteBased on record review and interviews, the facility failed to ensure behavior monitoring was conducted for target behaviors related to the use of psychotropic medications of one (#133) of five residents reviewed for psychotropic medications of 38 sample residents. Specifically, the facility failed to track and monitor target behaviors and have a personalized care plan for Resident #133, who was ordered a psychotropic medication.