North Point Healthcare & Wellness Centre LP

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure gloves were changed between dirty and clean tasks for 2 (Resident #7 and Resident #76) of 2 sampled residents reviewed for pressure ulcer/injury.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the licensed nursing staff clarified a medication order with the physician. The pharmacy sent empagliflozin 10 milligrams (mg) to the facility 26 times from 10/2024 to 03/2025 and the licensed nursing staff never informed the physician that the medication was being delivered and the pharmacy never notified the physician that the medication had been ordered by the resident's cardiologist for 1 (Resident #28) of 4 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were two errors out of 35 opportunities, which resulted in a 5.71% medication error rate for 1 (Resident #28) of 4 residents observed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of three boiler system (a device that heats water) burner tray was full of dust, debris, and water deposits across burners used to heat water for resident's shower rooms and residents room sink faucets. This failure contributed for a non-functioning boiler system and scheduled residents' showers on 1/11/25 were not provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, and homelike environment for 13 of 37 sampled residents when the ceiling light in the dining room was not working and did not provide adequate lighting to meet residents needs. This failure resulted for 13 residents in the facility who routinely used the dining room to have decreased visibility inside the dining room which had the potential to result in eye straining, falls and accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for five of five sampled residents (Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56) when Physician Orders for Life Sustaining Treatment (POLST- a portable form with instructions for emergency medical care that travels with a resident) was not completed in its entirety. These failures had the potential for Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56's medical information to not be readily accessible and portable in case of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 74) when Resident 74 was re-admitted to the facility on [DATE]. This failure had the potential for Resident 74 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 37 sampled residents (Resident 11, Resident 12) when: 1. Resident 11 did not have a care plan for the change of texture of his dessert. This failure had the potential to result for Resident 11's dietary safety needs to go unmet which could lead to aspiration or choking, and poor oral intake. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of care for one of three sample residents (Resident 46) when the nasal cannula (a flexible tube that goes around your head and into your nose and helps deliver supplemental oxygen) and humidifier (a plastic bottle designed to attached to oxygen machines and add moisture to the end users oxygen) for Resident 46 was undated. This failure placed Resident 46 at risk for respiratory infection which could lead to serious medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 299) received treatment and care in accordance with professional standards of practice when Resident 299's serum glucose (a type of sugar in the body) were not reported to the physician according to the physician's orders. This failure placed Resident 99 at risk for hypoglycemia (when the level of glucose in the blood drops below what is healthy), or hyperglycemia (high blood glucose), and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when Dietary Supervisor (DS) did not wear a hairnet while walking around in the dry storage area inside the kitchen. This failure had the potential to cause foodborne illness to residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff possessed appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one of one Director of Staff Development (DSD) when the DSD did not have a process in place to verify the mandatory staff dementia (the loss of cognitive function)competency trainings and in-services of Registry staff (contracted staff). This failure had the potential to place resident who suffer from dementia care at risk when placed under the care of a registry staff who did not complete the required dementia competency training and in-services mandated by State and Federal regulations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen sanitation water bucket used to sanitize food preparation and distribution surface kitchen areas contained manufacturer's recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens). This failure had the potential to spread foodborne illness (disease or period of sickness caused by food contamination) to residents that were served meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment with an effective infection prevention and control program to prevent the development and transmission of communicable (spreads from one person to another) disease and infections when: 1. One of two direct care staff Certified Nurse Assistant (CNA) 3 did not perform hand hygiene (techniques to clean the hands, including handwashing with plain and antimicrobial soaps and/or the use of alcohol-based hand rubs) after touching mask and before putting on Personal Protective Equipment (PPE). 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a person-centered care plan for one of one sampled resident (Resident 6) when Resident 6 acquired multiple bruises on his left and right arms from IV (Intravenous -a needle with tube, inserted into a vein to give medications or fluids) line infiltration (when the IV solution leaks into the tissue or skin around the insertion site) and a care plan was not implemented to monitor healing of the bruises. This failure had the potential for Resident 6's IV infiltration and bruising not being monitored for skin infection and bleeding complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for two of five sampled residents (Residents 34, and 47) when: 1. Resident 47 was administered oxygen (medical gas) at 4 liters (L- unit of measurement) per minute by way of nasal cannula (tubing used to deliver oxygen) instead of oxygen at 2L in accordance with the Physician's order for shortness of breath. This failure resulted in Resident 47 receiving a higher dose of oxygen than ordered from the physician and had the potential for compromised lung function due to high doses of oxygen. 2. Resident 34 was not administered his nutritional supplement (supplement containing vitamins, minerals, and extra calories) for the month of September 2021 and October 2021 according to the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a comprehensive resident assessment and ensure treatment was initiated in accordance with professional standards of practice for one of one sampled resident (Resident 6) when Resident 6's skin was not accurately assessed to develop an individualized treatment and monitoring plan to monitor multiple bruising on Resident 6's left and right arms. This failure had the potential to result in Resident 6 not receiving treatment and monitoring to the multiple bruises on Resident 6's left and right arms which placed Resident 6 at risk for undetected bleeding and skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 48) received food prepared in a form that meets individual swallowing needs during the lunch meal service on 2/2/22. This failure had the potential to place Resident 48 at increased choking risk and decreased nutritional intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete and contained accurately assessment documentation in accordance with professional standards of practice for one of one sampled resident (Resident 6) when Licensed Vocational Nurse (LVN) 4 did not document Resident 6 bruising on his left and right arms from the intravenously (IV -is a pliable tubing with a needle used to administer hydration fluids, medication, blood, or nutrients in the vein) insertions. This failure resulted in an inaccurate and incomplete clinical record for Resident 6 and resulted in Resident 6's bruising to go without monitoring or treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a safe environment when one of three Housekeeping (HK) carts, HK cart 3 was left in the hallway unattended and cleaning product [brand name] was accessible to residents. This practice failed to ensure environment was maintained safe for Residents.