Northcrest Rehab and Nursing Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of the fall investigation, review of staff statements, and review of the facility policy, the facility failed to follow the care plan and the information on the Kardex (mechanism that provides Certified Nursing Assistants the care needs of the residents) when providing care to a dependent resident. This resulted in Actual Harm on 02/10/26 when Resident #11 fell out of bed and sustained a laceration to the back of her head. This affected one (Resident #11) of three residents reviewed for falls. The facility census was 59.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policies, the facility failed to ensure proper infection control practices were implemented related to COVID-19 droplet isolation and contact isolation. This affected four (#37, #28, #56 and #12) residents and had the potential to affect all 29 residents on the 300 and 400 halls (#1, #2, #3, #4, #7, #9, #10, #13, #16, #18, #20, #22, #26, #27, #30, #34, #36, #40, #41, #42, #44, #45, #46, #47, #48, #49, #51, #58, and #163). The facility census was 62.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure fingernails were kept cleaned and trimmed on a dependent resident. This affected one resident (#2) of one resident reviewed for clean and trimmed nails. The facility census was 62.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to apply brace/splint per physician order. This affected one (#55) of one resident reviewed for position and mobility. The facility census was 62.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected two residents (#15 and #48) of two residents reviewed for falls. The facility census was 62.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure medications were stored in a proper manner. This affected two (Residents #22 and #16) of two residents observed for medication storage. The facility census was 62. 1. Review of the medical record for Resident #22 revealed an admission date of 01/05/23 and a readmission date of 09/04/24 with diagnoses of chronic obstructive pulmonary disease and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had impaired cognition. Review of the Self-Medication Assessment, completed 12/04/24, revealed Resident #22 was unable to self-administer medications. Observation on 01/21/25 at 9:20 A.M. revealed a bottle of aspirin, dose 325 milligrams (mg), lying on top of Resident #22's bedside cabinet. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to obtain blood glucose levels as ordered. This affected one (#11) of three residents observed during medication administration. The facility census was 59.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to maintain resident indwelling urinary catheters in an effective and sanitary manner. This affected one (#3) of one residents reviewed for urinary catheter care and function. The facility census was 59.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician, and within prescribed time frames, resulting in a medication error rate above five (5) percent (%). This affected two (#9 and #10) of three residents observed during medication administration. A total of two medications errors were observed out of 29 opportunities for a medication administration error rate of 6.9%. The facility census was 59.

Inspectors wroteBased on observation and staff interview the facility failed to maintain resident common showers in a sanitary manner. This affected all 27 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #24, #25, #26, #27) residing on the 100 and 200 halls. The facility census was 61.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed in accordance with physician orders. This affected one (#1) of three residents reviewed for wound care. The facility census was 61.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure resident nutritional supplements were administered and monitored in accordance with physician orders. This affected one (#1) of three residents reviewed for nutritional support interventions. The facility census was 61.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure clean bed linens were provided to the residents. This affected one (#4) of three residents reviewed for clean and sanitary bed linens. The facility census was 61.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility protocol, the facility failed to ensure wound treatments were administered in accordance with physician orders. This affected one (#4) of four residents reviewed for skin integrity. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure provide an assessment, including measurements and staging, of a pressure ulcer identified upon admission, and failed to initiate treatments timely when pressure ulcers were identified. This affected one (#63) of three residents reviewed for pressure ulcers. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to monitor Resident #19's skin underneath a heel protector boot. This resulted in actual harm when Resident #19 developed two Deep Tissue Injuries (DTI) on the right foot, consistent with the strap of the heel protector boot being too tight. Additionally, the facility failed to complete accurate skin assessments and failed to ensure recommended interventions were in place for Resident #60. This resulted in actual harm when Resident #60 was discovered with an in-house acquired DTI to the foot. This affected two (Residents #19 and #60) of three residents reviewed for skin breakdown. The facility's census was 64.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure a clean and sanitary environment when fecal matter was observed in a resident hallway. This had the potential to affect all 18 (#3, #4, #6, #12, #14, #17, #26, #27, #28, #32, #33, #39, #40, #42, #45, #48, #51, and #54) residents who resided on the hall. The facility census was 64.

Inspectors wroteBased on staff interview and observation, the facility failed to ensure residents had privacy curtains. This affected one resident (Resident #3) of 64 reviewed for privacy. The facility census was 64.

Inspectors wroteBased on staff interview, record review, and review of the facility's abuse policy, the facility failed to report an allegation of resident to resident verbal abuse. This affected two (Residents #17 and #6) of three residents reviewed for abuse. The facility census was 64.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure a comprehensive care plan was developed to address safe smoking for one (Resident #53) of three residents reviewed for smoking. The facility census was 64.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming services was provided to a dependent resident. This affected one (Resident #43) of three residents reviewed for receiving assistance with Activities of Daily Living (ADLs). The facility census was 64.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide restorative care as ordered. This affected one (#35) resident reviewed for range of motion. The facility census was 64.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility smoking policy, the facility failed to ensure supervision was provided to a resident assessed as requiring supervision during smoking. This affected one (Resident #20) of two residents reviewed for smoking. The facility census was 64.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to implement specific dietary interventions to potentially prevent weight loss. This affected one (Resident #20) of four residents reviewed for nutritional management. The facility's census was 64.

Inspectors wroteBased on medical record review, resident interview, and staff interviews, the facility failed to ensure a resident was seen by a physician as required. This affected one (Resident #35) of one resident reviewed for physician visits. The facility census was 64.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to ensure call lights functioned properly in resident rooms. This affected two residents (#14 and #40) of 64 residents reviewed for call light functioning. The facility census was 64.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to properly store foods for resident use. This failed practice affected 82 of 84 resident identified by the facility who received meals from the facility. Residents #43 and #44 did not receive meals from the kitchen. The facility census was 84.

Inspectors wroteBased on medical record review, observation, resident and staff interview and policy review, the facility failed to provide grooming care to a resident who was unable to carry out activities of daily living (ADL) independently. This affected one (Resident #29) of 21 sampled residents reviewed for ADLs. The facility identified 82 of 85 residents required assistance with grooming. The facility census was 84.

Inspectors wroteBased on medical record review, observation, resident and staff interview and facility policy review, the facility failed to assess, document and properly treat non-pressure wounds for Resident #132. This affected one (Resident #132) of two residents reviewed for non-pressure related wounds. The facility identified five residents identified by the facility with non-pressure wound treatments. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to attempt non-pharmacological interventions prior to the administration of as needed (PRN) anti-anxiety medications. This affected one resident (Resident #12) of five residents reviewed for unnecessary medications. The facility identified ten residents who received anti-anxiety medications. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to ensure infection control practices were maintained. This affected one (#48) of two residents reviewed for indwelling urinary catheters. The facility identified three residents with indwelling urinary catheters. Additionally, the facility failed to provide infection control measures when providing wound treatments. This affected one (Resident #19) of two residents observed for wound treatments of non-pressure related skin issues. The facility identified five residents with non-pressure related wound treatments. The facility census was 84.