Northbrooke Post Acute

Inspectors wroteBased on policy review, medical record review, observation, and interview, it was determined the facility failed to follow physician orders, failed to provide pressure ulcer/injury treatments, and failed to ensure a pressure reducing mattress was properly implemented for 3 of 3 (Resident #20, #47 and #63) sampled residents determined to have pressure ulcers/injuries.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 3 of 6 staff member (Registered Nurse (RN)I, Licensed Practical Nurse (LPN) J ) left medication unattended, and out of sight, and opened oral medications were stored in a medication cup, when a medication was stored at bedside in 1 of 79 occupied rooms, when 1 of 6 medication carts (300 hall) was left unlocked, unattended, and out of sight of staff, when 3 of 6 ( 300 hall, 200 hall, and the short stay) medication carts had holes/cracks in the drawers.

Inspectors wroteBased on policy review, observation, refrigerator and freezer temperature logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. Food items stored unlabeled and undated, stored beyond use by date, and stored on freezer floor. Staff personal items sitting on workstation on top of equipment. Plastic storage containers and lids were dirty with sticky residue, metal table with rust on surface, ice machine had fuzzy debris hanging out of filter, and food trays stored with standing water on them. Drinks sitting out uncovered. Hand hygiene not performed when plating food and loading meal cart. The facility failed to maintain temperature logs for two nourishment refrigerator/freezers. The facility had a census of 79 with 74 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held at least quarterly for 3 of 25 (Resident #4, #17 and #28) sampled residents reviewed for care plan meetings.

Inspectors wroteBased on the facility policy, Patient Trust record review and interview the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 2 of 19 (Resident #35 and #51) sampled residents reviewed for personal funds.

Inspectors wroteBased on policy review, medical record review, withdrawal record review, and interview, the facility failed to refund 3 of 3 (Resident #329, #330, and #331) resident's account balances within 30 days of death.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to provide information to the residents regarding their right to formulate an advance directive for 13 of 25 (Residents #4, #11, #17, #27, #30, #34, #37, #49, #61, #62, #278, #279, and #478) residents reviewed for advance directives.

Inspectors wroteBased on policy review, medical record review, observations and interview the facility failed to obtain a Physician's Orders for foley catheter care for 1 of 25 (Resident #6) sampled residents reviewed for urinary catheter care and failed to follow physician orders for 1 of 25 (Resident #63) sampled residents, and

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow interventions to prevent falls for 1 of 4 (Resident #328) reviewed for falls.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings when staff failed to ensure the enteral feeding, the feeding syringe and the flush solution were properly labeled for 2 of 3 sampled residents (Resident #11 and Resident #61) reviewed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings.

Inspectors wroteBased on policy review, medical record review, observation, and interview the facility failed to obtain physician orders, failed to ensure the physician orders were being followed, and failed to accurately care plan for 3 of 4 (Residents #29, #36, #478) sampled residents reviewed for respiratory therapy.

Inspectors wroteBased on review of the facility's Licensure Staffing Requirements, daily staffing schedules, and interview, the facility failed to ensure a Registered Nurse (RN D and MDS Coordinator) was on duty at least 8 hours a day, 7 days a week, for 2 of 28 days reviewed.

Inspectors wroteBased on policy review, daily staff posting review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed staff responsible for resident care on the facility's Daily Staff Posting form for 31 of 31 sampled days.

Inspectors wroteBased on Resident Rights, medical record review, and interview, the facility failed to maintain accurate medical records related to Cardiopulmonary Resuscitation (CPR) for 1 of 1 (Resident # 378) sampled residents reviewed for CPR.

Inspectors wroteBased on the CDC's [Center for Disease Control] Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings review, policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 79 occupied rooms contained a blood-tinged gauze, when 1 of 1 staff members (Certified Nurse Assistant (CNA) L) failed to properly store soiled linens, and when 5 of 5 staff members (Registered Nurse (RN) D and RN I, Licensed Practical Nurse (LPN A), CNA B and CNA L) failed to wear Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Contact Precautions, when 1 of 6 staff members ( LPN K failed to properly disinfect reusable medical equipment, when 1 of 6 staff members (LPN H) failed to properly store an enteral syringe, and when 3 of 3 staff members (LPN C, LPN [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure staff was following physician orders for a Percutaneous Gastrostomy (PEG) tube feeding and failed to date and label PEG tube feedings for 2 of 2 (Resident #43 and #73) sampled residents reviewed for enteral feedings.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the cooking stove, unlabeled and undated food items, and expired food items. The facility had a census of 88 with 84 of those residents receiving a tray from the Kitchen.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 13 staff members (Certified Nurse Aide (CNA) A and B and Licensed Practical Nurse (LPN) C ) failed to perform proper hand hygiene during meal service and the facility failed to ensure precautions were followed to prevent spread of infections, failed to handle and store linens to prevent the spread of infection, and failed to ensure hygiene procedures were followed by staff when 4 of 4 staff members (Housekeeper D, Certified Nurse Assistant (CNA) A, and Licensed Practical Nurse (LPN) E and O) did not wear personal protective equipment (PPE) in a resident's room, when CNA A placed a dirty incontinent brief and a dirty incontinent pad on the resident's floor, and when CNA A and LPN E failed to perform hand hygiene.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure staff maintained residents' dignity and respect when 2 of 13 staff members (Certified Nursing Assistant (CNA) A and CNA B) failed to knock and announce themselves before entering a resident's room during dining and during a random observation.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 10 of 59 resident rooms (Resident #7, #12, #26, #28, #41, #43, #51, #52, #66, #189).

Inspectors wroteBased on policy review, medical record review, review of the ADL (Activities of Daily Living) Verification Worksheets, Night shift shower assignment sheet, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to bathing and showering was provided for 3 of 20 (Resident #31, #35 and #74) sampled residents reviewed for ADL care.

Inspectors wroteBased on policy review, medical record review, observation, and interview the facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer wound for 2 of 4 sampled residents (Resident #73 and #189) reviewed for pressure ulcers. The facility failed to provide ordered wound care and failed to ensure a pressure reducing mattress was properly implemented.

Inspectors wroteBased on policy review, observations and interviews, the facility failed to ensure all licensed nurses independently demonstrated competency while providing care and services for 2 of 6 Nurses (Licensed Practical Nurse (LPN) L and LPN O) observed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to store all drugs and biologicals in locked compartments when a medication cart was left unlocked and unattended for 1 of 7 medication storage areas (Medication Cart 1) and when medications were left at the resident's bedside for 1 of 23 sampled resident's rooms (Resident #19).

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary with a recapitulation of the resident's stay, and failed to provide discharge instructions and reconciliation of medications to the residents' representatives on discharge from the facility for 3 of 3 sampled residents (Resident #84, #85, and #285) reviewed for discharge.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment and failed to ensure fall risk assessments were completed for 6 of 6 sampled residents (Resident #18, #28, #74, #184, #185, and #186) reviewed for accident hazards and falls.

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, Employee Time Punch Reports, Employee Screening Logs, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 27 of 106 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14, Registered Nurse (RN) #1, and Licensed Practical Nurse (LPN) #3, #4, #5, #6, #7 #8, #9, #10, #11, #12, #13, and #14) failed to complete screenings for the prevention and detection of COVID-19 prior to work for 16 of 17 days (3/19/2022, 3/20/2022, 3/22/2022, 3/23/2022, 3/24/2022, 3/25/2022, 3/26/2022, 3/27/2022, 3/28/2022, 3/29/2022, 3/30/2022, 3/31/2022, 4/1/2022, 4/2/2022, 4/3/2022, and 4/4/2022) reviewed. The facility had a census of 89.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to notify the Responsible Party for 1 of 5 sampled residents (Resident #28) reviewed for accidents hazards.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure the care plan was implemented and followed for fall interventions for 1 of 1 sampled resident (Resident #184) reviewed for falls.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow the facility's policy for monitoring weights for 1 of 5 sampled residents (Resident #67) reviewed for nutrition.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow the physician orders to monitor the oxygen flow rate for 1 of 4 residents (Resident #23) reviewed for respiratory services.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were securely locked, stored, and inaccessible to residents, unauthorized staff, and visitors when 2 of 9 medication storage areas (300 Hall Medication Cart and Treatment Cart) were found unlocked and unattended.