Northgate Care Center

Inspectors wroteBased on observation, record review, and staff, doctor, pharmacist interview, and policy review the facility failed to have 4 of 7 nurses administer medications following the 6 rights of medication administration. The 6 rights are a process of verifying the right resident, right drug, right dose, right route, right time, and right documentation performed to systematically minimize medication errors, ensure patient safety, and maintain the efficacy of treatment. By verifying these key factors, healthcare providers prevent adverse events, protect residents, and adhere to safety protocols. [...]

Inspectors wroteBased on observation, staff, and pharmacist interviews, and policy review the facility failed to store medications in the pharmacy labeled package for all residents on 2 of 8 days of the survey. The facility also failed to keep insulin pens in a locked container/cart/room and keep narcotic in a double locked container/cart/room. The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to make a good faith attempt and ensure effective quality assurance processes regarding significant medication errors when a deficient practice with F760, Residents are Free of Significant Medication Errors, was cited at the facility for 3 of 4 onsite surveys, which included the current survey, since 9/1/2024. The facility reported a census of 44 residents.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to implement infection control measures when 6 of 6 morning insulins were stored together in a container (Resident #30, #14, #43, #19, #2, and #4). The facility also failed to provide Enhanced Barrier Precautions (EBP) as the Centers for Disease Control and Prevention (CDC) (an infection control strategy for nursing homes and long-term care facilities to reduce the spread of multidrug-resistant organisms, It involves using gowns and gloves during high-contact care for residents with wounds, indwelling devices, or known multi-drug resistant organism colonization) directs during wound care (Resident #37). The facility also failed complete routine glove change and hand hygiene during pressure ulcer care after cleaning the wound for 1 of 1 residents (Resident #37). The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff interviews and policy review the facility failed to provide informed consent regarding the risk and benefits for as needed psychotropic medications (medications that affect brain activity, influencing mood, thoughts, behavior, and perception to treat mental health conditions) for 1 of 3 residents reviewed for antipsychotic medications (Resident #7). The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff interviews and policy review the facility failed to ensure non-pharmacological interventions were in place and anti-psychotics were used to treat relevant diagnoses and not a behavior (agitation) for 1 of 3 residents reviewed (Resident #38). The facility reported a census of 44 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to code 1 of 2 residents catheter (Resident #38), 1 of 1 resident pressure ulcer (Resident #37), and 1 of 2 residents Preadmission Screening and Resident Review (PASRR) outcome (Resident #8) on the Minimum Data Set (MDS) assessment to reflect their current status at the time of the MDS assessment. The facility reported a census of 44 residents.

Inspectors wroteBased on observation, and resident and staff interviews the facility failed to provide care routine skin monitoring to cancerous lesions on the scalp and resident requested assessment/treatment for 1 of 3 residents reviewed for skin conditions (Resident #36). The facility also failed to maintain documentation that Neurological assessments (often called neuro checks) were performed after unwitnessed falls for 3 of 7 falls that indicated a need for neuro assessment monitoring (to detect serious, hidden brain injuries that might not be obvious right away, because bleeding or swelling in the brain can develop slowly over hours or even days, these tests are repeated to monitor for changes in a person's condition) for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility reported a census of 44 residents.

Inspectors wroteBased on observation, record review, staff interviews and policy review the facility failed to provide restorative programs as directed for 2 of 2 residents reviewed for restorative and develop/implement a restorative treatment policy for the facility to follow (Resident #36 and #7). The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to complete a root cause analysis after each fall to ensure an intervention to prevent future falls was put in place, and failed to ensure the intervention was related to the reason the fall occurred for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility also failed to update the Care Plan timely related to falls for Resident #7. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, staff interview, facility video, and facility policy review the facility failed to properly assess and intervene for 2 of 3 residents reviewed, (Residents #3 and #8). The facility identified a census of 45 residents.

Inspectors wroteBased on observation, facility video review, resident interview, staff interview and facility policy review, the facility failed to follow appropriate infection control practices during direct resident cares for 3 of 3 residents reviewed. (Resident #1, #3 and #4) The facility identified a census of 45 residents.

Inspectors wroteBased on observation, video footage review, clinical record review, staff interview and review of the facilities Resident [NAME] of Rights, the facility failed to maintain the dignity and respect during cares for 2 of 3 residents reviews. (Resident #3 and Resident #4). The facilities identified a census of 45 residents.

Inspectors wroteBased on clinical record review, staff interview, family interview, hospital staff interview and facility policy review the facility failed to notify 1 of 3 resident family members/representatives which pertained to a condition change and/or medication error. (Resident #3) The facility identified a census of 42 residents.

Inspectors wroteBased on clinical record review, staff email and a Skin Quick Reference form, the facility staff failed to maintain complete and accurate Care Plans for 1 of 3 residents reviewed. (Resident #8) The facility identified a census of 45 residents.

Inspectors wroteBased on staff interview, resident interview and facility policy review the facility failed to answer resident call lights in a timely manner, within 15 minutes and provide enough staff to meet the individual needs of the residents for 2 of 2 residents reviewed. (Resident #2 and #4) The facility identified a census of 45 residents.

Inspectors wroteBased on the facilities video footage review, clinical record review and staff interview the facility failed to assure 2 of 3 residents remained free of significant medication errors. (Resident #3 and #5)

Inspectors wroteBased on clinical record review, staff interview, a Licensed Practical Nurse (LPN) Job Description form and facility policy review, the facility failed to maintain complete and accurate resident records for 2 of 3 residents reviewed. (Resident #3 and #5) The facility identified a census of 45 residents.

Inspectors wroteBased on record review and staff and resident interviews the facility failed to give 1 of 3 residents the correct medications and inadvertently gave him another residents medications that included anti-psychotic medication resulting in over sedation and admission to the hospital for observation (Resident #1). The facility reported a census of 39 residents.

Inspectors wroteBased on observation, policy review, and staff interviews the facility failed to keep bare hands off the drinking surfaces of glasses in order to serve meals under sanitary conditions for 1 of 1 meals observed. The facility reported a census of 39 residents.