North Ridge Health and Rehabilitation Center

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was served under safe and sanitary conditions. This practice had the potential to affect more than 4 of the 56 residents residing in the facility. Staff did not use utensils while plating lunch items, including diced tomatoes, shredded lettuce, shredded cheese, soft shell tortillas, and bread. R14, R15, and R16's medical records indicated they were allergic to tomatoes. R14, R15, and R16 received potentially cross-contaminated lunch items on 4/14/26.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food preferences were honored for 1 resident (R) (R9) of 4 sampled residents. R9's 4/14/26 lunch ticket listed R9's meal preferences. R9 was served two items R9 requested not to receive.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 42 of 53 residents residing in the facility. (Eleven residents received nutrition via tube feeding). Staff did not monitor wash or rinse temperatures for the low-temp chemical sanitizing mechanical warewashing machine. The mixer was not covered. Staff working in the kitchen did not consistently cover facial hair.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R7) of 1 sampled resident with a Guardian was protectively placed in the facility. R7 was admitted to the facility on [DATE] and had a legal Guardian of person and estate beginning 9/11/20. The facility did not have protective placement determination for R7.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure freedom from physical restraints imposed for the purpose of discipline or convenience and not required to treat medical symptoms for 1 resident (R) (R49) of 1 sampled resident. The facility's Restraint Free Environment policy, revised 2/5/25, indicates: The resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use .a physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R42) of 5 sampled residents met the Preadmission Screening and Resident Review (PASRR) requirements. R42 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R42 received a qualifying diagnosis and was prescribed medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was consistently checked for placement, function, and skin integrity underneath for 1 resident (R) (R42) of 1 sampled resident. R42's Treatment Administration Record (TAR) contained orders to check for WanderGuard placement, function, and skin integrity. The checks were not consistently completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure assessments, vital signs, and weights were consistently completed pre- and post-dialysis and communicated to the dialysis facility for 1 resident (R) (R9) of 1 sampled resident. Staff did not consistently obtain R9's pre- and post-dialysis vitals signs and weight or check R9's access port. In addition, staff did not consistently complete R9's dialysis communication sheets and Treatment Administration Record (TAR).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R31) of 19 sampled residents. Medications were left at R31's bedside for R31 to self-administer. R31 did not have a self-administration of medication assessment, a physician order, or a care plan that indicated R31 could safely and accurately self-administer medication.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 4 residents (R) (R1, R5, R4, and R3) of 9 sampled residents. In addition, the facility did not ensure narcotic medication was consistently reconciled. These practices had the potential to affect more than 4 of the 57 residents residing in the facility. R1, R5, R4, and R3's medications were not administered in accordance with the ordered administration time and facility policy. Nursing staff did not complete controlled substance counts at shift change.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled residents received the appropriate care and services to promote healing and/or prevent pressure injuries from developing. R1 had a stage 3 presure injury on the coccyx upon admission. R1's wound care was not provided in accordance with a physician's order on 7/6/25. R1 developed a wound infection that required intravenous (IV) antibiotics and debridement.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R2) of 1 resident reviewed for elopement. An elopement risk assessment, dated 1/31/25, indicated R2 was at risk for elopement. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R2's left ankle. On 6/12/25 at 3:10 AM, R2 eloped from the facility and was found at approximately 3:55 AM approximately two miles from the facility. An investigation determined R2 exited the facility through the 200 wing door which had an alarm that sounded, however, staff were unable to hear the alarm because they were in residents' rooms providing care. Staff did not respond to the alarm until approximately 3:15 AM. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 39 of the 54 residents residing in the facility. There were 15 residents who received nutrients exclusively via tube feeding. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not follow appropriate hand hygiene procedures when they prepared and served food. Resident food and beverages were not served at appropriate temperatures.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R4) of 13 sampled residents. R4 was diagnosed with yeast in the urine and had an order for antibiotic treatment. R4's Power of Attorney for Healthcare (POAHC) was not notified of the change in condition or antibiotic treatment. In addition, R4 had low blood pressure readings on 5/10/25 and 5/11/25. R4's physician and POAHC were not notified.

Inspectors wrote2. On [DATE], Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of glottis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and tracheostomy status. A care plans, initiated on [DATE], indicated R6 had a Clostridioides difficile (C. diff) infection (a highly contagious bacterium that causes diarrhea and colitis) and was on contact precautions. On [DATE] at 1:25 AM, Surveyor observed CNA-R and CNA-S enter R6's room without donning PPE. Surveyor observed a sign posted on R6's door that indicated R6 was on contact precautions. Surveyor observed CNA-R and CNA-S prepare to transfer R6 from bed to wheelchair. CNA-S applied R6's socks and shoes while CNA-R retrieved R6's wheelchair and a gait belt. CNA-R then applied the gait belt and assisted R6 to the wheelchair. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure guardianship and protective placement orders were obtained and advance directive wishes were followed for 4 Residents (R) (R31, R43, R39, and R30) of 17 sampled residents. R31 had a legal guardian at the time of admission on [DATE]. R31's medical record contained petitions for guardianship and protective placement, dated 9/28/22; however, R31's medical record did not contain guardianship or protective placement orders. R43 had a legal guardian at the time of admission on [DATE]. R43's medical record contained an Order and Notice of Hearing on Guardianship and Protective Placement, dated 3/23/24, with a hearing date of 5/6/24; however R43's medical record did not contain guardianship or protective placement orders. R39 had a legal guardian at the time of admission on [DATE]. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. Three of 4 medication carts were observed unlocked and unattended. In addition, 2 of 2 medication carts and 1 of 2 mediation storage rooms contained expired medication and medical supplies. This practice had the potential to affect multiple residents in the facility. Medication carts on the 500, 600, and 300 wings were unlocked and unattended on 8/12/24 and 8/13/24. Medication carts and the medication storage room on the 200 and 300 wings contained expired medications and medical supplies.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 33 of 47 residents residing in the facility. (Fourteen residents received nutrition exclusively via tube feeding.) Kitchen equipment and food service areas were not kept in a clean and sanitary condition to prevent cross contamination. Staff did not perform appropriate hand hygiene and safe food handling practices when cooking and serving food. Staff did not document food holding temperatures. The resident refrigerator and reach-in cooler contained food and beverages that were past the discard date or not labeled with a discard date.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 7 Residents (R) (R36, R2, R9, R17, R11, R16, and R4) of 10 residents. On 8/12/24, staff did not complete appropriate hand hygiene during wound care for R36. On 8/12/24 and 8/13/24, staff did not wear masks or complete hand hygiene appropriately during the provision of care for R2. On 8/13/24, staff did not wear appropriate personal protective equipment (PPE) during a therapy session with R9 who was on enhanced barrier precautions (EBP). On 8/13/24, staff did not complete appropriate hand hygiene or wear required PPE during a transfer for R17 who was on EBP. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R11, R16, and R41) of 3 sampled residents were assessed as able to safely and accurately self-administer medication. On 8/12/24, License Practical Nurse (LPN)-U left medication with R11 for R11 to self-administer after breakfast. R11 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R11 could safely and accurately self-administer medication. On 8/12/24, LPN-U left medication at R16's bedside for R16 to self-administer. R16 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R16 could safely and accurately self-administer medication. On 8/12/24, Registered Nurse (RN)-K prepared a nebulizer treatment for R41 to self-administer. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R9) of 9 sampled residents had a call light within reach. R9's plan of care contained an intervention to be sure R9's call light was within reach. During an observation on 8/12/24, R9's call light was not within reach.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the medical record contained advance directives for 1 Resident (R) (R13) of 17 sampled residents. R13 was admitted to the facility on [DATE]. R13's medical record did not contain advance directives, including a Power of Attorney for Healthcare (POAHC) document.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R12, R23, and R31) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R12 was transferred to the hospital on 7/23/24. R12's activated Power of Attorney for Healthcare (POAHC) did not receive a written transfer notice. R23 was transferred to the hospital on 1/11/24. R23 was not provided with a written transfer notice. R31 was transferred to the hospital on 9/12/23, 10/21/23, 3/8/24, and 4/20/24. R31's court-appointed guardian did not receive written transfer notices.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R12, R23, and R31) of 3 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R12 was transferred to the hospital on 7/23/24. R12's activated Power of Attorney for Healthcare (POAHC) was not provided with a written notice of the bed hold policy. R23 was transferred to the hospital on 1/11/24. R23 was not provided with a written notice of the bed hold policy. R31 was transferred to the hospital on 9/12/23, 10/21/23, 3/8/24, and 4/20/24. R31's court-appointed guardian was not provided with written notices of the bed hold policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R31) of 5 residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R31 had multiple healed pressure and deep tissue injuries and received wound care to prevent the injuries from re-opening. During observations on 8/12/24, R31's wound care orders and care plan interventions were not implemented as ordered.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 Resident (R) (R38) of 1 resident reviewed for smoking. R38 was known by the facility to smoke cigarettes. The facility did not assess R38's ability to safely smoke on a quarterly basis in accordance with the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vital signs and weights were consistently completed pre- and post-dialysis and communicated to the dialysis facility for 1 Resident (R) (R30) of 1 resident reviewed for dialysis. Staff did not consistently complete R30's dialysis communication sheets and did not consistently obtain R30's pre- and post-dialysis vital signs and weights.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monthly medication reviews were completed or followed-up on for 2 Residents (R) (R36 and R39) of 5 residents reviewed for unnecessary medication. R36 had a pharmacist recommendation from R36's October 2023 monthly medication review (MMR). The recommendation was not addressed until 2/5/24. In addition, R36 did not have an MMR documented for March of 2024. R39 had a pharmacist recommendation from R39's November 2023 MMR. The recommendation was not addressed at the time of the annual survey.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate submission of mandatory staffing information based on payroll data in a uniformed electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 47 residents residing in the facility. Staffing data for fiscal quarter 1 (date range: 10/1/23-12/31/23) and quarter 2 (date range: 1/1/24-3/31/24) of the Payroll Based Journal (PBJ) were not submitted accurately to CMS.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it served pasta salad at a safe and appetizing temperature. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 50 residents who received nutrition via enteral feeding. On 7/9/24, the temperature of cold pasta salad was 61.7 degrees Fahrenheit (F).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 50 residents who received nutrition via enteral feeding. Staff did not perform proper hand hygiene prior to donning/doffing gloves, while preparing food, prior to touching ready to eat food, and while throwing away garbage.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate care and treatment were provided when 1 resident (R) (R1) of 12 sampled residents experienced a change of condition. On 5/5/24, R1 experienced a change of condition. Staff did not document complete and accurate assessments regarding R1's change of condition or notify R1's physician in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R10 and R11) of 4 residents with a percutaneous endoscopic gastrostomy (PEG) tube (a medical procedure in which a tube is passed into the stomach through the abdominal wall) received treatment and services to prevent adverse consequences of enteral feeding. Staff did not obtain weights for R10 and R11 in accordance with physicians' orders.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menu items were prepared according to the recipe and served according to the extended menu for 1 resident (R) (R13) of 1 resident who was on a pureed diet. During lunch service on 7/9/24, staff did not follow the pureed food recipe and did not use an appropriate serving size to serve pureed chicken.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it served milk at a safe and appetizing temperature. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 52 residents who received nutrition via enteral feeding. On 5/20/24, the temperature of milk served on a test tray was 53.6 degrees Fahrenheit (F).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed appropriate hand hygiene during food preparation. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 52 residents who received nutrition via enteral feeding. On 5/20/24, [NAME] (CK)-C did not consistently perform appropriate hand hygiene during food preparation.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R2) of 2 sampled residents. R2 was not monitored after a change in condition which resulted in a hospitalization for septic shock.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary or food service manager, who had a national certification for food service management and safety from a national certifying body, or who had an associate level or higher degree in food service management or hospitality. This had the potential to affect 44 out of 57 residents who resided in the facility. (Thirteen residents were exclusively tube fed.)

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 44 of 57 residents residing in the facility. (Thirteen residents received nutrition exclusively via tube feeding.) Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Cook (CK)-N did not wait two minutes to take microwave reheated food temperature to ensure food was heated evenly. Staff did not ensure food-contact and non-food contact equipment, including a can opener, stove griddle, oven, and double oven were clean and dry for storage or use. The facility did not monitor and document hot holding temperatures. The facility did not cool foods with an approved food cooling method.

Inspectors wroteBased on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 4 Residents (R) (R30, R53, R44 and R50) of 5 sampled residents. The facility did not accurately complete PASRR Level I Screens and/or submit PASRR Level II Screens for R30, R53, R44, and R50.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menu serving sizes for pureed and mechanically altered diets were followed for 8 Residents (R) (R58, R20, R10, R43, R8, R4, R3, and R41) of 44 residents. The facility served smaller serving portions than the menu indicated for pureed green beans, pureed polish sausage on a bun and mechanically altered polish sausage during the lunch meal on 6/13/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 Resident (R) (R35) of 2 sampled residents reviewed for new admission. R35 was admitted to the facility with diagnoses including tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), gastrostomy (an artificial external opening into the stomach for nutritional support) and ventilator (a machine used medically to support or replace the breathing of a person) dependence. R35's baseline care plan did not address the diagnoses.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R50 and R58) of 5 residents reviewed for Activities of Daily Living (ADLs) were provided weekly showers. R50 was admitted to the facility on [DATE] and had four documented showers since 4/1/23. R58 was admitted to the facility on [DATE] and had one documented shower since 5/1/23.

Inspectors wroteBased on staff interview and record review, the facility did not obtain weights as part of nutritional monitoring for 2 Residents (R) (R58 and R35) of 4 sampled residents reviewed for nutrition. R58 did not have an order on admission for weight monitoring. The facility's policy stated to obtain weights weekly for four weeks and monitor residents with weight loss weekly. R35 had an order for weekly weights and a tube feeding (TF) rate of 60 ml/hr (milliliters/hour). The facility did not consistently monitor R35's weight on a weekly basis or ensure the TF rate was followed per physician order.

Inspectors wroteBased on staff interview and record review, the facility did not ensure high-risk medications were monitored for 2 Residents (R) (R33 and R44) of 5 residents reviewed for unnecessary medications. R33 and R44's medical records did not contain documentation that R33 and R44 were monitored for potential side effects of diuretic medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure potential side effects and adverse reactions for a psychotropic medication were monitored for 1 Resident (R) (R44) of 5 residents reviewed for unnecessary medications. R44 was prescribed lorazepam (an anti-anxiety medication). The facility did not include monitoring for side effects or adverse reactions to the medication in R44's plan of care.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure Residents (R) on a pureed diet had meals prepared by a method that conserved nutritive value for 2 (R20 and R58) of 2 residents with pureed diets. Kitchen staff used water to puree multiple food items which did not conserve the nutritive value of the food.

Inspectors wrote2. On 6/12/23 at 11:24 AM, Surveyor observed CNA-K and CNA-E provide perineal care for R17. CNA-K and CNA-E cleansed hands and donned the appropriate personal protective equipment (PPE). CNA-K opened the tabs of R17's soiled brief and tucked the front end of the brief underneath R17's buttocks. CNA-K provided perineal care with a wet, soapy washcloth. With the same gloved hands, CNA-K dried R17's perineal area with a towel. CNA-K then removed and disposed of R17's soiled brief. With the same gloved hands, CNA-K touched furniture, cream, powder and a clean brief. CNA-K then removed gloves. Without cleansing hands, CNA-K donned clean gloves, placed a clean brief under R17's buttocks and applied cream to R17's buttocks. CNA-K then removed gloves. Without cleansing hands, CNA-K donned clean gloves and closed the tabs on R17's brief. [...]