Northgate Health and Rehabilitation Center

Inspectors wroteBased on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' rights to be free from sexual and physical abuse perpetrated by residents. Specifically: 1.) The facility failed to ensure Resident Identifier (RI) #49 was free from sexual abuse perpetrated by RI #1, a resident with a history of sexually inappropriate behavior to include vulgar comments and obscene language. On 09/12/2024 RI #1was found unsupervised in the Activity Room with his/her hand on RI #49's breast. [...]

Inspectors wroteBased on interviews, record review, and review of a facility policy titled Unnecessary Drugs the facility failed to ensure adequate monitoring for behaviors was completed accurately, properly, and consistently while a Gradual Dose Reduction (GDR) for a psychotropic medication was being attempted. Specifically, RI #1 had a dose reduction of Seroquel on 08/28/2024 and the facility did not have a documented system to include timeframe and instructions to staff on monitoring for behaviors while a GDR attempt was in progress. The Certified Nursing Assistant (CNA) and the nurses' behavior monitoring documentation on the Electronic Medication Record (EMAR) was not completed accurately and in a manner to validate whether RI #1 had behaviors or escalation of behaviors. [...]

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Services, the facility failed to ensure residents with behaviors were managed and addressed to protect other residents from abuse, and to ensure other residents' safety and privacy was protected from residents with combative, aggressive, and sexual behaviors. Specifically, 1.) The facility failed to ensure staff documented the presence of or absence of target behaviors that were identified in Resident Identifier (RI) #1's Care Plan to ensure RI #1's behaviors were managed. RI #1 had diagnoses of Schizophrenia and Bipolar Disorder and a history of sexually inappropriate behavior. On 09/12/2024 RI #1 was found by staff in the Activity Room unsupervised with RI #49 and RI #1 had his/her hand on RI #49's breast. [...]

Inspectors wroteBased on interview and review of the Dietary Manager's (DM) employee file, the facility failed to have a qualified Dietary Manager. This had the potential to affect 60 of 60 residents receiving meals from the kitchen.

Inspectors wroteBased on observations, interviews, record review and review of a facility policy titled, Safe and Homelike Environment, the facility failed to ensure residents were provided a safe, clean, comfortable, and homelike environment. During the survey the following concerns were observed in Residents' rooms and common areas: 1) Resident Identifier (RI) #2, RI #7, RI #24, RI #25, RI #31, RI #38 and RI #43 had areas of walls and trim in their rooms in need of painting; 2) RI #1, RI #2, and RI #25 had window blinds in their rooms with broken or missing pieces; 3) RI #15 and RI #25 had windowsills in their rooms in need of repair; 4) RI #26 had a dresser with chipped paint; 5) The Unit Two hallway had broken and stained ceiling tiles; 6) RI #31 and the hallway on Unit Two had as wall with detaching trim; 7) RI #43 had a wall with a hole behind the door and missing pieces of floor tiles. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure: 1) hand rails in the hallways were not missing plastic end cap pieces, 2) a small handrail was not missing from the wall on the left side of the hall, and there was not a missing handrail on the right side of the hallway on Unit One; and 3) a small hand rail was not missing from the wall next to the nurses station on Unit Two. This deficient practice was identified during observations of the environment and had the potential to affect residents who ambulated in the facility.

Inspectors wroteBased on interviews, record review and review of a facility policy titled, Notification of Change, the facility failed to ensure Resident Identifier (RI) #312's sponsor/representative was notified when RI #312 had a room change in the facility on 10/18/2024. This deficient practice affected RI #312, one of 27 sampled residents and was cited as a result of the investigation of complaint/report number AL00049381.

Inspectors wroteBased on observations, interviews, resident record review, and review of the Centers for Medicare & (and) Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to ensure Resident Identifier (RI) #21's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/28/2025 was coded to accurately reflect that RI #21 received special treatment of dialysis. This deficient practice had the potential to affect RI #23, one of 27 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on interviews, medical record review, review of a facility policy titled, Diagnostic Testing Services, and a review of a Facility Incident Report (FRI) received by the State Agency, the facility failed to ensure RI #412's laboratory services were provided timely when an order was received on 07/19/2024 to obtain a Urinalysis (UA) and Culture and Sensitivity (C&S) for RI #412. This deficient practice affected RI #412, one of 27 sampled residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure Resident Identifier (RI) #29's bed was in a safe operating condition at all times. During the dinner meal on 04/29/2025, RI #29's head of bed (HOB) was observed to be in a flat position. Certified Nursing Assistant (CNA) #23 reported the bed had been broken since 04/28/2025. This affected RI #29, one of 27 sampled residents.

Inspectors wroteBased on observations, interview, and review of a facility policy titled, Nurse Staffing Posting Information, the facility failed to ensure the total hours staff actually worked were included on the nurse staff forms posted in the facility on 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, and 05/03/2025. This deficient practice was observed on five of 11 days of the survey, and had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and review of a facility policy titled Code of Dress and Personal Appearance the facility failed to ensure: 1.) the Dietary Manager (DM) wore a beard guard around food while in the kitchen on 01/06/2025 and 01/08/2025; 2.) Residents were served on dinnerware instead of paper plates during the evening dining observation on 01/06/2025 and; 3.) the kitchen stove hood and vents were clean and free of a grease and dust like substance on 01/06/2025 during the initial tour of the kitchen. This had the potential to affect 52 out of 52 residents who received meals from the kitchen. 1.) A review of a facility policy titled Code of Dress and Personal Appearance dated 2020, revealed: . Guideline: All Dining Services employees will comply with printed and posted personal hygiene guidelines, sanitation practice, and dress code of this community. Procedure: . a. [...]

Inspectors wroteBased on observations, interviews, resident record review, and review of a facility policy titled Nebulizer Therapy the facility failed to ensure Resident Identifier (RI) #8's nebulizer mask and tubing was maintained in a manner to prevent contamination on four of four days of the survey from 01/06/2025 through 01/09/2025 when RI #8's nebulizer mask was not stored in a zip lock bag per policy and RI #8's nebulizer mask and tubing had not been changed since 12/22/2024. This deficient practice affected RI #8, one of two residents sampled for Respiratory Care.

Inspectors wroteBased on observations, interviews, record review, review of facility policies titled, Pest Control Program and Safe and Homelike Environment, review of complaints received by the Alabama State Survey Agency, the facility failed to ensure: 1) rodent droppings were not observed in the Dietary Manager's (DM) office, dry storage room in the kitchen, and in the nurses medication room, 2) an adhesive strip with multiple size roaches was not in Resident Identifier (RI) #24's bathroom, and adhesive strips with dead roaches were not in the kitchen, 3) an exit door near RI #'s 26 room did not have a gap beneath the door; and 4) there were not numerous complaints from residents about roaches/rodents being in the facility. [...]

Inspectors wroteBased on observations, interviews, record review and review of a facility policy titled, Safe and Homelike Environment, the facility failed to ensure: 1) the privacy curtain in Resident Identifier (RI) #14's room was not stained and dirty, 2) the smoke detector in RI #25's room was not detaching from the ceiling, 3) there was not a hole in the wall on Station II adjacent to RI #24's room, 4) two tiles were not missing from the floor outside of RI #25's room. These deficient practices affected RI #14, RI #24, and RI #25, three of 26 sampled residents: one of one medication room and one of two units at the facility. This deficiency was cited as a result of the investigation of complaint/report numbers AL00048404 and AL00048134. Finding Include: Review of a facility policy titled, Safe and Homelike Environment, with a Copyright date of 2024, revealed the following: Policy: [...]

Inspectors wroteBased on observation, interviews, record review and review of a facility policy titled, Promoting/Maintaining Resident Dignity, the facility failed to ensure Certified Nursing Assistant (CNA) #7 did not stand while feeding Resident Identifier (RI) #6 the lunch meal on 07/30/2024. This deficient practice affected RI #6; one of one resident observed being fed by facility staff. Findings Include: Review of a facility policy titled, Promoting/Maintaining Resident Dignity, with a Copyright date of 2023, revealed the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity . [...]

Inspectors wroteBased on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #12's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/02/2024, was coded to reflect RI #12 receive an anticoagulant medication during the assessment period. This deficient practice affected RI #12, one of 26 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, revealed the following: . SECTION N: MEDICATIONS . Coding Instructions . N0410E, Anticoagulant . [...]

Inspectors wroteBased on observation, interviews, record review and review of a facility policy titled, Pressure Injury Prevention Guidelines, the facility failed to ensure there was not an unidentified Stage II pressure injury to the back of Resident Identifier (RI) #12's right leg when the Treatment Nurse completed a body audit for RI #12 on 08/01/2024 with the surveyor. This deficient practice affected RI #12, one of five residents sampled for pressure injury. This deficiency was cited as a result of the investigation of complaint/report #AL00048404. Findings Include: Review of a facility policy titled, Pressure Injury Prevention Guidelines, with a copyright date of 2023, revealed the following: Policy: [...]

Inspectors wroteBased on interviews, record review and review of facility policies titled, Fall Prevention Program, and Safe and Homelike Environment, the facility failed to ensure Resident Identifier (RI) #7 did not have a fall due to water being on the floor from a leaking air conditioner (AC) unit in RI #7's room. This deficient practice affected RI #7, one of five residents sampled for Falls. This deficiency was cited as a result of the investigation of complaint/report number AL00048404. Findings Include: Review of a facility policy titled, Fall Prevention Program, with a Copyright date of 2023, revealed the following: . A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level . The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . [...]

Inspectors wroteBased on observation, interviews, record review and review of a facility policy titled, Hand Hygiene, the facility failed to ensure Certified Nursing Assistant (CNA) #7 performed hand hygiene after removing her gloves after feeding Resident Identifier (RI) #6 the lunch meal and leaving RI #6's room on 07/30/2024. This deficient practice affected CNA #7; one of three staff observed for infection control practices. Findings Include: Review of a facility policy titled, Hand Hygiene, with a Copyright date of 2023, revealed the following: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility. Definitions: [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility policies titled Wound Care and Personal Protective Equipment-Gloves, the facility failed to ensure the treatment nurse did not cross back over Resident Identifier (RI) #14's wound three times using the same gauze while cleaning RI #14's wound on 5/5/2021. Further, during the provision of RI #14's wound care, the treatment nurse failed to wash or sanitize her hands between glove changes. This affected one of three sampled residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, interviews and review of facility policies titled Clean Linen Handling and Handwashing/Hand Hygiene, the facility failed to ensure: 1. A Certified Nursing Assistant (CNA) did not hold a clean spread against her body while she was outside in the smoking area smoking a cigarette then place the spread over Resident Identifier (RI) #4; and 2. A CNA washed hands and changed gloves between tray delivery and set-up while passing out meal trays to RI #18, 21, and 35. These failures affected four of 26 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and review of a facility policy titled Handwashing/Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands or used hand sanitizer after she gave Resident Identifier (RI) #57's oral medications , picked up a straw from the floor with her right hand, and listened to RI #57's lung sounds with her stethoscope, prior to putting on gloves to give RI #57's nebulizer treatment. This affected one of three residents observed during medication administration pass and one of three nurses observed during medication administration pass. Findings Include: A review of a facility policy titled Handwashing/Hand Hygiene, with a revised date of 7/05/2017, revealed . This facility considers hand hygiene the primary means to prevent the spread of infection . [...]