Northern Pines Rehabilitation and Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain a safe environment for 1 (#16) of 19 sampled residents, as evidenced by unsecured medications stored in the resident's bedside nightstand.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the privacy of personal health information, when a resident's height and weight were posted outside of the resident's door in a public location for 1 (#15) of 19 sampled residents. This deficient practice caused the resident to be disgusted by the posting.

Inspectors wroteBased on interview and record review, the facility failed to maintain evidence of Ombudsman notification for a resident who was transferred to the hospital for 1 (#6) of 19 sampled residents. This deficient practice limited the Ombudsman's opportunity to review the facility's transfer protocols.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess a resident's diagnosis of dementia for 1 (#2) of 19 sampled residents. This deficient practice had the potential to prevent the resident from achieving his highest practicable physical and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to include wound care on the 48-hour baseline care plan for a newly admitted resident with multiple wounds for 1 (#44) of 19 sampled residents. This deficient practice resulted in staff not knowing the specific care requirements for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively care plan and implement the use of a hand splint to prevent further left hand and wrist contractures for 1 (#6); and failed to include a diagnosis of dementia and interventions for 1 (#2) of 19 sampled residents. The deficient practice increased the risk of further contractures for the resident and had the potential to keep the residents from meeting their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary treatments and services to a resident with wounds, to promote healing of the wounds, and the physician's orders for the wound treatments were not implemented in a timely manner, for 1 (#44) of 19 sampled residents. This deficient practice increased the risk of infection and worsening of the wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the need for and have processes in place to ensure resident personal refrigerators were maintained and monitored for 1 (#31) of 19 sampled residents. This deficient practice caused the residents' refrigerator to become dirty and to contain expired foods, which could have led to illness.

Inspectors wroteBased on observation and interview, the facility failed to employ a certified dietary manager or full-time dietician to oversee the dietary department duties. This deficient practice increased the risk of nutritional issues for all residents who received or will receive services from the dietary department.

Inspectors wroteBased on interview and record review, the facility failed to complete background checks on 6 (Staff IDs: O, L, R, N, M, and I) employees of 9 sampled employee files, prior to their start date in the facility. This deficient practice had the potential to put all residents at risk for abuse, neglect, exploitation, or misappropriation.

Inspectors wroteBased on interview and record review, the facility failed to report two allegations of abuse to the State Survey Agency within the required two-hour time frame for 1 (#1); and failed to report investigation findings to the State Survey Agency for 3 (#s 2, 5, and 10) of 12 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to fully investigate an abuse allegation for 5 (#s 4, 5, 7, 8, and 10) of 12 sampled residents. This deficient practice increased the risk of ongoing concerns of abuse due to the investigations being incomplete.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff followed professional standards for medication administration before administering a controlled substance for 1 (#3) of 12 sampled residents. This deficient practice resulted in the administration of a controlled substance without a current physician's order on three separate days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards by failing to effectively use a fall prevention program, root cause analysis, identify and implement appropriate interventions, and ensure staff used the interventions appropriately, for 3 (#s 7, 25, and 27) of 17 sampled residents. The on-going failure led to resident #25 sustaining a head laceration, requiring staples and an overnight stay in the hospital; resident #7 sustaining a head laceration requiring staples, a hip hematoma, and bruising on the left temple; and resident #27 sustaining a hematoma above the left eye and bloody nose. On 11/20/24 at 4:30 p.m., the facility Administrator and administrative staff were notified of an Immediate Jeopardy involving resident #25, pertaining to F689 - Free of Accident Hazards/supervision/devices. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the director of food and nutrition services met the education qualifications required by CMS for a food service director, which increased the risk of residents being affected negatively since the director provided oversight for the entire dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to serve food in accordance with professional standards for food service safety, by not wearing hairnets, while in food service areas. Failure to uphold food safety may affect any resident at the facility.

Inspectors wroteBased on interview and record review, the facility administrator failed to provide adequate oversight and training for the Administrator in Training (AIT), and the DON, with regard to the responsibilities of the interdiscipliary team reviews and processes to be used, and how to conduct a performance improvement project related to the fall prevention protocol, for 3 (#s 7, 25, and 27) for 18 sampled residents; and the administrator failed to ensure the facility employed a certified Infection Preventionist, and failed to ensure the facility employed a qualified Dietary Manager which may affect any resident at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Infection Preventionist was qualified through an approved certification program prior to assuming the role of Infection Preventionist. The deficient practice had the potential to affect all residents receiving care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a facility policy which contained the name and contact information for the grievance official; failed to provide forms within reach of residents who were unable to stand to reach the grievance forms; and failed to provide residents with the option to file grievances anonymously, for 4 (#s 15, 22, 25, and 32) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered hand hygiene before meals in the dining room for 1 (#22) of 18 sampled residents; and failed to follow appropriate infection control practices for proper hand hygiene between resident contact for 4 (#s 2, 19, 25, and 32) of 5 sampled residents for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective antibiotic stewardship program to include adequate monitoring of antibiotic use for 2 (#s 2 and 30) of 18 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were in reach for residents to call for assistance for 3 (#s 7, 25, and 27) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from verbal and physical abuse by other residents for 2 (#1 and #11) of 18 sampled residents. During the survey, it was found the facility had previously identified, investigated, and corrected the non-compliance for the abuse between resident #1 and resident #11.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 1 and 11); and failed to submit the results of an investigation within 5 working days for 1 (#12) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to complete accurate MDS coding for 2 (#s 19 and 24) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to revise an individualize comprehensive care plan to reflect the current management and interventions for a mental health diagnosis, for 1 (#30) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice by administering insulin by pen without first priming the pen. This deficient practice caused the resident to receive 2 units less insulin than prescribed and had the potential to cause an elevated blood glucose for 1 (#19) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay, and a post-discharge plan of care, for 1 (#34) of 2 residents sampled for a closed record review.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents did not receive medication without an adequate indication for its use for 1 (#30) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 (#30); and failed to complete the gradual dose reduction for 1 (#25) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for 2 (#s 7 and 25) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the required SNF ABN, Form CMS-10055 to 2 (#11 and #15) of 3 sampled residents who received Medicare Part A skilled services, and it was found the facilit had not been completing them at all for any resident.

Inspectors wroteBased on observation, interview, and record review, the facility was sharing nursing staff throughout their shifts with the connected assisted living without properly scheduling and coding on the accrued time on records. The facility failed to ensure the facility licensed nurses were always working in the nursing home. This deficient practice had the potential to affect any resident needing assistance in the nursing home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was weighed after an illness and hospitalization, for the identification of weight changes. This deficient practice delayed the identification of the resident's severe weight loss, for 1 (#5) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed ensure adequate monitoring, glucose administration, and insulin parameters were in place for diabetic residents for 1 (#27) of 1 sampled resident. This deficient practice had the potential to affect any resident receiving insulin. During observations on 11/18/23 - 11/19/23, resident #27 was not observed to get out of bed or join any of the meals. Trays left at her bedside went untouched. During an observation and interview on 11/19/23 at 4:42 p.m., resident #27 was lying in bed and stated she hadn't had much to eat and was very sleepy. Review of resident #27's MAR, dated November 2023, showed she had an order for Blood Glucose AC and HS before meals and at bedtime related to .Diabetes mellitus with hyperosmolarity with coma. There were no high or low physician notification parameters. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (#11) of 17 sampled residents. This practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed have a certified person to serve as the director of food and nutrition services. This practice had the potential to affect all residents.

Inspectors wroteBased on observation and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This practice had the potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and update the infection prevention policies annually; failed to ensure staff provided proper infection control practices of hand hygiene for residents when providing meal service; and failed to perform hand hygiene when changing gloves after providing cares for 1 (#11) of 17 sampled residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide treatments, as ordered, by the physician, and identify and document skin breakdown in accordance with professional standards of practice, and for maintaining the resident's quality of life, over multiple days and shifts, for 1 (#9) of 17 sampled residents. It was identified the resident had at least six areas of skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship program was followed with monitoring and tracking of antibiotic use for 1 (#29) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to fully inform and obtain a verbal or written consent containing the complete explanation of risks versus benefits with a resident's POA, prior to giving a psychotropic medication, for 1 (#23) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to have consistent code status information in the resident's medical record, for 1 (#20) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the ongoing re-evaluation of bolsters placed on the resident's bed, to ensure they were not utilized as restraints, for 1 (#11) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change assessment for a resident with a severe unavoidable weight loss, who had medications discontinued, and she was placed on comfort care, for 1 (#1) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a person-centered, comprehensive care plan for 2 (#s 28 and 29) of 17 sampled residents. This deficient practice had the potential for the resident's needs, safety, and well-being to be unfulfilled.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan to reflect ongoing interventions for recurrent falls for 1 (#29) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion services to a resident who had decreased range of motion and a hand contracture, for 1 (#11) of 17 sampled residents; failed to provide range of motion services for a resident with bilateral lower extremity contractures for 1 (#12) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean nebulizer equipment for 1 (#11) of 17 sampled residents, increasing the risk for respiratory infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store medications in locked compartments for 2 (#8 & 9) of 17 sampled residents; and failed to ensure expired medications and supplies were removed from the medication room, supply closet, and medication cart.

Inspectors wroteBased on interview and record review, facility staff failed to respond to a door alarm sounding, for 1 (#3) of 4 sampled residents, and the resident had a fall in the parking lot.