Northgate Postacute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative nursing services (RNS) were provided to three of three sampled residents reviewed for RNS (Resident 1, Resident 2 and Resident 3) when services were not provided as ordered by the physician (MD) or provided without an order, not as scheduled and care planned or without active care plans. This failure decreased the facility's potential to provide residents with appropriate services to maintain or improve their limitations in range of motion and mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to professional standards for one of three sampled residents reviewed for medication administration (Resident 1) when he was not given his blood pressure medication per the physician's (MD) order and missed doses on two consecutive days. This failure had the potential to result in elevated blood pressure and increased leg swelling for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident 1) of five sampled residents from misappropriation (the unauthorized use of another person's property or money without permission) of property when Staff 1 made unauthorized charges to Resident 1's credit card. This failure resulted in Staff 1 misappropriating $27,571.50 from Resident 1's bank account which would leave a reasonable person upset, disturbed and financially injured.

Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough background screening for one employee (Staff 1) when Staff 1's criminal background check results indicated it was incomplete. This failure decreased the facility's potential to protect and prevent abuse to their resident population.

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight hours a day for four days in July 2025. This failure had the potential to result in inadequate care for a medically fragile population of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed five percent when seven identified medication errors out of 26 opportunities were observed:1. The wrong form of aspirin was administered to Resident 29 and Resident 34.2. Senna (medication used to stimulate bowel movement) and docusate sodium (medication used to soften bowel movements) were not held in accordance with the physician order for Resident 25.3. Resident 25 was not instructed to chew a chewable aspirin.4. The wrong form of Vitamin C was administered to Resident 25.5. Resident 25 did not receive dapagliflozin (medication used to treat diabetes mellitus- a condition when the body doesn't create enough insulin) when ordered. [...]

Inspectors wroteThis REQUIREMENT is NOT MET as evidenced by:Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and prepared under sanitary conditions when: 1) Staff food items were stored in Refrigerator #2 with the resident food items.2) An unlabeled and undated container of peaches was stored in Refrigerator #2 and was not properly disposed of.3) A dietary staff member with facial hair was observed in the kitchen preparing lunch for the residents without a beard restraint.4) Chopped salad was observed outside the cold holding temperature of 41 degrees Fahrenheit (measurement of temperature) or below. These failures had the potential to place residents at risk for developing food-borne illnesses (sickness by consuming contaminated food or drinks) by exposing residents to contaminated food and unsanitary practices.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain three out of 13 resident bathrooms when they were found in disrepair. This failure had the potential to result in an unsanitary and uncomfortable homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when Licensed Vocational Nurse (LVN 1) provided wound care to one of 15 sampled residents (Resident 1) without a physician's order. This failure had the potential to result in delayed wound healing for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure collaborative care with the contracted hospice agency was provided for one of 15 sampled residents (Resident 36). This failure had the potential to affect Resident 36's safety and comfort of care.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations for two of two employees (Certified Nursing Assistant [CNA] 3 and CNA 4). This failure had the potential to result in an inability to correct poor performance and compromise patient safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of used fentanyl patches (potent opioid medication used to pain management). This failure had the potential to result in drug diversion, inaccurate medication accountability and unsafe medication management.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely store and label drugs in accordance with acceptable standards of practice when:1. One medication cart was left unlocked and unattended. This failure had the potential to result in residents and staff obtaining unauthorized access to medications and supplies that could lead to adverse effects.2. An open bottle of Senna syrup (laxative medication used to stimulate a bowel movement), stored in the medication cart did not have an expiration date. This failure had the potential to result in Senna syrup having a reduced effectiveness, potential bacterial contamination and unpredictable side effects.

Inspectors wroteThis REQUIREMENT is NOT MET as evidenced by the following:Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of when trash was observed on the ground and in an unsecured garbage dumpster, creating an unsanitary environment with the potential to attract pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hospice services met professional standards for one of 15 sampled residents (Resident 36) when:1. The Hospice Registered Nurse (HRN) left Resident 36 exposed to the public for approximately 22 minutes, with no clothes from the waist to the feet.2. The Hospice Registered Nurse's (HRN) conduct was unprofessional towards Resident 36. These failures had the potential to cause physical and psychosocial harm to Resident 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the need to place one of 15 sampled residents (Resident 37) on Enhance Barrier Precautions (EBP-infection control strategy used to prevent spread of bacteria), while having multiple open wounds. This failure had the potential to result in the spread of dangerous multidrug-resistant organisms (MDROs) among the residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in a safe and operating condition when:One of the laundry machine was covered in rust and was broken. The bed locks for Resident 36 were not working. These failures had the potential to affect the resident's health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one handrail was secured to the wall. This failure had the potential to result in residents utilizing an unstable handrail that could subsequently cause a sudden fall and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of two sampled residents (Resident 1) of their responsibilities as a resident when Resident 1 ' s daily rate for room and board increased twice (on 1/1/24 and 1/1/25) with no advanced written notice and required a security deposit with no advanced written notice. These failures caused financial hardship to Resident 1 who stated, It ' s really ruined my life, and stated she felt poor.

Inspectors wroteBased on interview and record review, the facility failed to maintain signed admission agreements for three of five sampled residents (Residents 1, 2, and 3), and failed to give one of five sampled residents (Resident 1) a copy of the admission agreement. This failure resulted in Resident 1 having no documentation of what daily room rate or security deposit she had agreed to pay on admission, and had the potential to result in Resident 2 or 3 having no document for reference when they need information about the terms of their admission.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Thoroughly investigate an allegation of misappropriation of property per policy, 2. Implement the plan to protect other residents from theft, 3. Maintain a theft and loss log, and 4. Incorporate reported incidents of misappropriation of property into the facility quality assurance and performance improvement (QAPI) program for two of two residents (Resident 1 and Resident 2) with reports of missing debit cards and money missing from their bank accounts. These failures put vulnerable residents at risk of misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits for one resident (Resident 1)of three sampled residents timely. This failure had the potential to delay detection of declining health and the provision of care.

Inspectors wroteBased on interview and record review the facility failed to maintain documentation and present evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program implementation and activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the infestation of roaches when: 1. Live and dead cockroaches were observed in the pantry and food preparation areas in the kitchen where residents ' food was stored and prepared; 2. Pest technician recommendations for the control of the roaches were not followed; and, 3. The bedroom of two residents (Resident 1 and Resident 2), had roaches crawling in and around their beds causing Resident 1 to stop eating the food from the facility. These failures created an environment for harboring of pests and the potential for contamination of the food prepared and served.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was invited to participate in quarterly care conferences (interdisciplinary meetings to review and revise residents care plans). This failure deprived Resident 1 from providing input into the care and services provided to him at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was seen by a physician at least every 60 days. This failure had the potential for Resident 1 not to receive medical care.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three residents (Resident 1) when Resident 1 did not receive Restorative Nursing Services (RNS-range of motion and other physical exercises to promote safety and independence, provided by Restorative Nursing Assistants (RNAs)) according to physician orders. This failure placed Resident 1 at risk of not achieving her highest practical physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received physician visits at least every 60 days after admission when Resident 1 did not receive a physician visit for a period of 152 consecutive days during her stay at the facility. This failure had the potential to deprive Resident 1 of physician care.

Inspectors wroteBased on interview and record review, the facility failed to provide 5 of 5 sampled residents wanting to be discharged (Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5) with a discharge planning process which addresses each resident's discharge goals and needs, including referrals to local contact agencies for placements (Finding a home to meet medical, functional and emotional needs of the residents after discharge from a health care facility), and involved the interdisciplinary team in developing the discharge plan. These findings resulted in severe emotional and psychological harm to Resident 5, including suicidal ideation (Thinking about planning suicide) with the development of a suicide plan by Resident 5, and depression and stress for all the residents involved.

Inspectors wroteBased on interview and record review, the facility did not provide discharge notices to the Long-Term-Care Ombudsman (A representative that assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), as required by the Federal regulations. For three of four sampled residents (Resident 10, Resident 11 & Resident 12), the facility was unable to provide documentation of discharge notices sent to the Ombudsman, but the Ombudsman office indicated the facility had discharged 13 residents in recent months and only provided discharge notices for 4 of them. In addition, some of the discharged notices included incomplete documentation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide RNA (A Certified Nursing Assistant [CNA] with special training, skills and knowledge that provides therapeutic or rehabilitative services to residents under the direct supervision of a licensed professional) therapy services to three of three sampled residents (Resident 5, Resident 6 and Resident 7) that had physician orders for these services. This could have resulted in inability for the residents to restore their functional body movements, be able to walk and become independent.

Inspectors wroteBased on interview, and record review, the facility did not have sufficient staff to meet the care needs of three of four sampled residents (Resident 7, Resident 8 & Resident 9) when they were not provided with activities of daily living (ADLs-Activities related to personal care such as bathing and toileting) as required, and call lights were not answered promptly. During the morning shifts of 9/17/23 and 9/18/23, only two Certified Nursing Assistant (CNAs) were assigned to provide ADL services to all 40 residents of the facility, an assignment of about 20 residents per CNA. In addition, staffing shortages occurred in all shifts. These findings had the potential to result in harm to the residents involved, inability for staff to respond to medical emergencies, and lack of health services provided to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services to 5 of 5 sampled residents wanting to be discharged (Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5). These residents were not provided with assistance in finding placements for discharge, and three of them stated not having State identification cards (IDs) or medical insurance cards. These findings had the potential to cause harm, stress, and frustration to the residents involved.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 6) was treated with dignity and respect, when her request to send a check to her sister for $5000.00 was not honored, her DPOA (Direct Power of Attorney- A legal document that authorizes someone else to handle certain matters, such as finances or health care, on another person's behalf) did not receive regular statements of Resident 6's trust account with the facility, and Resident 6 was not provided with requested petty cash from her trust account immediately upon request. This finding had the potential to result in frustration, sadness, depression, and anxiety for Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to replace or reimburse one of two sampled residents (Resident 5) for items that were lost during his stay at the facility, after having notified Administration about it. In addition, the facility policy on theft and misappropriation of property was extremely limiting and did not protect residents for personal property losses over $100.00. This finding had the potential to result in feelings of frustration, abuse, and sadness to Resident 5 and other potential residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge for one of five sampled residents (Resident 3) when they began the process of a facility-initiated-discharge and provided a 30-day discharge notice to Resident 3 without a discharge plan or having arranged placement (Appropriate and safe housing that meets the resident's needs) for him. This finding had the potential to result in an unsafe, inappropriate discharge which could have caused harm to Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control & prevention program to prevent the spread of COVID-19 when: 1) No designated screener was available in the front lobby to screen staff and visitors for COVID-19 prior to entry to the building, staff and visitors were not properly screened before entry to the building, and equipment was not cleaned and disinfected between use. The screening logs were not reviewed by Infection Preventionist (IP) after completion. 2) Laundry staff stored the dirty apron near the clean linen and resident's clothing in the clean section of the Laundry room. Dirty linen barrel was stored a foot away from the clean linen barrel. 3) No annual Infection Control Prevention training to the staff. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the laundry equipment in a safe operating condition when one of two washing machines had water leakage that created a rusted area about a foot in length on the ground and in the corner of the washing machine. This failure had the potential to result in injury to the staff and residents.

Inspectors wroteBased on Interview and record review, the facility failed to implement the facility's transfer and discharge Policy and Procedure for non-payment notice or follow Federal regulations. Letters of eviction notice were sent to Resident 25, Resident 29, Resident 22, Resident 5 and to a family of Resident 14. This failure resulted in anguish, fear and emotional stress to the residents and family involved.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their full-time Infection Preventionist (IP-The person designated by the facility to be responsible for the infection prevention and control program), was able to perform her IP role when she was assigned to work on the floor and provide direct patient care. This failure had the potential to result in breaks in infection control, which could have resulted in spread of COVID-19 and other pathogens among residents and staff at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety was maintained when: 1. A spoiled lettuce and potato were stored in the kitchen refrigerator and dry storage with other produce in good condition, and; 2. Undated and unlabeled perishable food items were left in a resident's room (Resident 12) at room temperature, for a prolonged period of time. These findings had the potential to result in food borne illness to Resident 12, and other residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to record the Covid-19 nasal swab test results of unvaccinated staff and visitors. This failure had a potential to result in spread of Covid-19 virus to residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, comfortable and homelike environment when: 1. The facility failed to ensure the only soap dispenser in a staff restroom was functional, and; 2. A large area of peeling paint was observed right next to Resident 20's bed. These findings had the potential to result in spread of infections, and discomfort and harm to Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS (Minimum Data Set-A federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) assessments were accurate and complete within the required timeframes for two of eight sampled residents (Resident 33 and Resident 191). This had the potential to result in inability for the facility to identify residents' preferences, goals of care, functional and health status, and strengths and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a registry staff (Unlicensed Staff D) was provided necessary information to care for a non-English speaking resident (Resident 32), when she was not informed this resident had a communication tool available. This had the potential to result in inability for Resident 32 to communicate with staff, which could have caused feelings of frustration and helplessness for Resident 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective system of accounting and accurate reconciliation of a controlled medication for one resident (Resident 10). This failure resulted in the unaccounted 3 ml lacking from the bottle of Morphine sulfate (opiate pain medication) of Resident 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate did not exceed 5% when two medication errors were noted among 29 medication administration observations. This failure resulted in a medication error rate of 6.9%. The failure also had the potential to cause adverse consequencies such as hypoglycemia (low blood sugar), upset stomach or diarrhea to Resident 36, and prevent the delivery of the correct dose of medication that could result to inadequate control of asthma and other respiratory disorder symptoms to Resident 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents' (Resident 12) dietary orders were followed, when staff failed to provide her with a standing order for coffee during her lunch meal. This had the potential to result in frustration and despair to Resident 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two of eight sampled residents (Resident 8 and Resident 96) from resident-to-resident abuse, when a verbal altercation between them, in which profanity was used, was overheard by staff, who failed to report it to facility administration, and initiate appropriate interventions to eliminate abuse and prevent reoccurrence. This failure resulted in reoccurrence of verbal aggression, and emotional distress, to Resident 8 and Resident 96.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents' rights when: 1. Four of six sampled residents (Resident 21, Resident 36, Resident 9 and Resident 27) complained of being called Momma and Poppa by facility staff; 2. Five of six sampled residents (Resident 21, Resident 36, Resident 9, Resident 27 and Resident 195) stated having heard facility staff speaking a language other than English in resident care areas; 3. Three of five sampled residents (Resident 1, Resident 36 and Resident 27) stated they had observed staff using personal cell phones during work hours, and; 4. Facility staff was observed not wearing identifying name badges, while other staff was observed wearing name badges which did not include their position or title. [...]

Inspectors wroteBased on interview and record review, the facility failed provide complete and timely discharge notices to the Ombudsman for three of fifteen sampled residents (Resident 33, Resident 8, & Resident 10) when: 1) One discharge notice provided to the Ombudsman did not include the address of the receiving facility, and; 2) Two discharge notices for planned discharges were provided to the Ombudsman after the residents had been discharged from the facility. These failures could have resulted in lack of protection for residents from being inappropriately discharged and lack of advocacy services for the residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain was managed within acceptable standards of care for one of seven sampled residents (Resident 30) when: 1) The facility did not ensure Resident 30's pain level was assessed and reassessed to ensure pain management was effective; and, 2) The facility did to ensure PRN (as needed) pain medication was administered to Resident 30, who had a documented pain level of 6 out of 10 on multiple occasions. These failures may have resulted in suffering and distress to resident 30, who passed away on 01/27/20, at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1) The pureed (food blended to the consistency of applesauce or milkshake texture) diet recipe was followed for nine residents; and, 2) The therapeutic menu was not followed for a resident on a renal, fortified diet. These failures led to residents receiving meals that did not meet their nutritional needs and further compromised their health status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1) The puree recipe for the roast beef entrée was not followed and did not have flavor; and, 2) Palatable meals were not provided to residents. This failure had the potential to affect the meal intake and nutritional status of nine residents who received a pureed diet and other residents who complained about the palatability of the meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage, according to standards of practice when: 1) Three serving scoops were found dirty with green and brown crusted substances and stored with clean serving utensils; 2) Sixteen plastic bowls were stored wet underneath a food prep counter; 3) Ten potatoes in a supply box of potatoes had black discoloration, were moist and soft to touch were not discarded; and, 4) The ice machine was not cleaned and maintained, according to manufacturer's instructions. These failures had the potential to cause widespread food-borne illness among all 43 residents who consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was accurate and complete when: 1) Pain assessment and reassessment was not documented for one of seven sampled residents (Resident 30); and, 2) Weekly Nursing Progress Notes were inaccurate for one of seven sampled residents (Resident 30). This failure had the potential to result in lack of lack of communication among the health care team, poor quality of care and inadequate pain management, for Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to notify the DEPARTMENT of an incident of abuse, when Licensed Staff overheard one resident (Resident 8) yelling at her roommate, using profane language and did not report the incident to facility administration or the required authorities. This failure resulted in abuse reoccurrence.

Inspectors wroteBased on interview and record review, the facility failed to inform and communicate the transfer or discharge of Resident 45 to the receiving facility when: 1) The medical doctor (MD) ordered to discharge Resident 45 to detox center. 2) The Licensed Nurse failed to report to the receiving facility of the care that Resident 45 received.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement its policy and procedure on Care Plan-Baseline (a baseline care plan must be developed for each resident within 48 hours of admission to the facility. There are no exceptions to this requirement for holidays, weekends, or night admissions, and the baseline care plan was required to address, at a minimum, the following: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, and Pre-admission Screening and Resident Review (PASARR) recommendations if applicable) for one of three sampled residents, Resident 144, when a baseline care plan was not completed within 48 hours after her admission and a summary provided to her. This failure had the potential to result in adverse events most likely to occur after admission (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered, comprehensive care plan for constipation, for one of seven sampled residents (Resident 30). This failure had the potential to result in ineffective, incompetent care to Resident 30, who required specific interventions for his disease condition.

Inspectors wroteBased on interview and record review, professional standards of practice were not followed when a Licensed Nurse failed to check a colostomy bag frequently for one of two sampled residents (Resident 30), who was known to remove his colostomy device during periods of confusion. This failure had the potential to result in skin breakdown, dignity issues, discomfort and harm to Resident 30.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement its policy and procedure on Medication Ordering and Receiving from Pharmacy, for one of eight sampled residents, Resident 195, when a blister pack (Blister pack contains designated sealed compartments, or spaces, for medicines to be taken at particular times of the day) did not indicate the physician had changed the directions for the use of Midodrine HCL (Midodrine Hydrochloride - a medication prescribed to treat low blood pressure caused by certain conditions). This failure had the potential to result in a significant medication error, which may cause adverse consequences to Resident 195.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food and nutrition service's department staff competently carried out kitchen duties in a safe, sanitary manner according to manufacturer's instructions when: 1) A kitchen staff member was unable to verbalize and demonstrate correct techniques related to testing sanitizer buckets; and, 2) A kitchen staff member was unable to demonstrate the correct technique for testing the dishwasher sanitation level. These practices had the potential to expose residents to food-borne illness, due to lack of staff training and monitoring of their duties.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the garbage container was completely covered when in used in the kitchen. This failure had the potential to expose the food prepared in the kitchen for residents, and clean dishware, to garbage waste and provide an environment which harbored pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control principles were followed when: 1. A clean linen cart was left partially uncovered while not in use, in a facility hallway, and; 2. A cooler, which contained stool and urine specimens, was placed right next to a sink which was used to obtain water for resident consumption. These failures had the potential to cause contamination of facility resources, spread of infections and water-borne illnesses to the residents of the facility.