Northland Rehabilitation & Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to properly transfer resident (Resident #1), in a safe manner, when staff did not use two staff members and the sit to stand lift (a mechanical lift used to transfer residents) from bed to shower chair, as directed in the resident's plan of care. The resident fell, resulting in a fracture to the right femur. Facility census was 95. On 04/21/2026 the Administrator was notified of the past noncompliance that began on 03/30/2026. The Administrator immediately began an investigation and audit to identify incorrect care plans. The administrator implemented corrective actions to include re-education for nursing staff to provide care as directed in each resident's care plan and Kardex. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve meals in accordance with facility policy and scheduled mealtimes. This affected two of five sampled residents (Resident #1 and Resident #2) The facility census was 97. Review of facility undated policy titled Dining Service Mealtimes, included, there should be no more than 14 hours between the time the evening meal is offered, and the breakfast meal is offered, or 16 hours if a substantial evening snack is provided. A substantial evening snack included a protein source and a fruit or bread source. Review of the facility mealtimes posted in the hallways and dining room showed:-Breakfast is served at 8:30 A.M.-Lunch is served at 12:30 P.M.-Dinner is served at 5:30 P.M.1. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to wear beard nets and hand wash while working in the kitchen, failed to maintain proper standards of cleanliness and storage in the kitchen area, and failed to take accurate temperature readings of cooked food items. This affected all residents by putting them at risk for a food borne illness. The facility census was 95. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to knock on a resident's door and wait for a response before entering which affected one of the 19 sampled residents, (Resident #57), and when staff stood to assist Resident #29 to eat. The facility census was 95. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not provide satisfactory meals or offer evening (HS) snacks to four residents (Resident #5, #60, #71, and #76), failed to honor resident menu choices for two residents (Resident #33 and #55), failed to serve meals according to one resident's preferences (Resident #8), failed to offer to one resident menu items prepared for the meal (Resident #11), and failed to offer condiments to the alternate dining room. This affected eight of 19 residents sampled. The facility census was 95. Review of the facility policy, Resident Rights, dated 12/2024, showed each resident residing in this community has the right and will be afforded the right to a dignified existence and self-determination. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for two residents (#111, #112). This affected two of 19 residents sampled. Facility census was 95. Request for a policy covering resident funds upon discharge was not provided by the facility;1. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Assistant (NA) registry prior to employment to ensure all newly hired employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect for four out of the 10 sampled employees and failed to check the Family Care Safety Registry (FCSR) prior to employment to ensure all newly hired employees did not have negative records/backgrounds for two out of 10 sampled employees hired since October 2024. The facility census was 95. Review of the facility's abuse policy, revised on 1/2024 showed- Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including staff, volunteers, and other residents. All employees will have a criminal and state/federal required criminal background checks completed prior to start of employment. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice, by not following physician orders regarding oxygen maintenance of tubing and/or oxygen flow rate on four of the 21 sampled residents, #30, #82, #107 and #108. The facility census was 95. Review of the facility's policy Oxygen Administration dated 3/20/25 showed:-to verify that there is a physician's order for oxygen administration;-to check the tubing connected to the oxygen cylinder or concentrator to assure that it is free of kinks;-to turn on the oxygen and start the flow of oxygen at the rate ordered. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff discarded expired medications and biologicals stored in the rehabilitation nurse's medication room. The sample size was 19 residents. The facility census was 95. Review of the facility's undated policy, Medication Administration, showed:Adherence to this medication administration policy is essential to ensure the well-being and safety of the residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy. Continuous improvement and open communication are encouraged to uphold best practices in medication administration. Residents who self-administer must have a profile only medication administration record (MAR) which lists their medications and indicates that they self-administer. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable disease and infections when the facility failed to ensure that staff used proper Enhanced Barrier Precautions (EBP) while providing cares for two of the 19 sampled residents (Resident #2 and # 10) and failed to ensure that new staff had completed a Tuberculin (TB) skin test prior to working. The facility census was 95. Review of the facility policy Infection and Prevention and Control Program (IPCP), dated 2019, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program when numerous flying insects were observed by three residents (Resident #60, #71, and #76) throughout the facility. This affected three of 19 residents sampled. Facility census was 95. Request for facility Pest Policy not provided; Record review of facility pest service, showed:- 7/11/25 Vendor observed fly activity around dumpsters and applied fly treatment. Food residue on equipment and food filth on walls and drains under dish machine, interior door left open;- 6/10/25 Vendor observed fly activity around dumpsters and applied fly treatment. Food residue on equipment and food filth on walls and drains under dish machine, interior door left open; 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one of 19 sampled residents (Residents #69) by not addressing incontinence care with person-specific goals, measurable objectives, and time frames in order to evaluate the resident's progress towards obtaining his/her goals. The facility census was 95. Review of the facility's Care Planning policy, dated 12/2024, showed:- Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual;- Upon completion of comprehensive assessments, CAAs will be triggered to flag areas of concern that may need to be addressed in the care plan for the resident;1. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store foods in sealed containers in the freezer, ensure the cleanliness of the ice machine, and use adequate hand hygiene during food service in one of one kitchen. These failures had the potential to cause the spread of foodborne illness to all 96 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for three of four residents (Resident (R) 247, R14, and R2) reviewed for implementation of EBP with chronic wounds or indwelling devices (intravenous (IV) line, enteral feeding tubes, urinary catheter, or central venous catheter) who were candidates for EBP of 25 sample residents. These failures created the potential to spread multidrug-resistant organisms (MDROs) throughout the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to report an allegation of verbal abuse to the State Survey Agency (SSA) for one out of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This failure had the potential to affect resident safety at the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to thoroughly investigate an allegation of verbal abuse for one of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This had the potential to affect resident safety in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised for two of three residents (Resident (R) 345 and R3) reviewed for care plan accuracy of 25 sample residents. Specifically, the facility failed to identify the inaccurate medical diagnosis for R345 and did not revise the care plan to address hospice services for R3. Failure to update the care plan could result in the residents not receiving care to meet their specific needs.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure pressure ulcer treatment orders and pressure ulcer prevention measures were implemented for one of two residents (Resident (R) 3) reviewed for pressure ulcers of 25 sample residents. These failures had the potential to lead to wound deterioration or the development of avoidable pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from unnecessary medications when one of five residents (Resident (R) 10) was given two separate doses of psychotropic medications without any documented clinical need for either medication of 25 sample residents. This failure had the potential to affect the safety of all residents who received psychotropic medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff obtained physician's orders and assessed residents for safe administration of medication to be kept at the bedside for two of four sampled residents (Resident #1 and #2). The facility census was 96. The facility provided no policy on medication administration. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/23, showed: -Cognitive skills intact; -Diagnoses included diverticulitis (an inflammation or infection in one or more pouches in digestive tract), diabetes (a disease that occurs when your blood sugar is too high), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in blood). Review of care plan, dated 11/6/23, showed the staff were to administer medications as ordered. [...]