Northridge Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and review of the facility-provided dietary recipes, the facility failed to ensure dietary staff followed recipes for preparing pureed meals to conserve the nutritive value and flavor for eight of eight residents (R) who received a puree diet from a total of 82 residents who received an oral diet from the kitchen.

Inspectors wroteBased on resident and family interviews, staff interviews, record review, and review of the facility policy titled, Patient Trust Fund, the facility failed to provide quarterly resident trust fund statements to one of 33 sampled residents (R) (R68).

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policy titled, Infection Prevention Plan, the facility failed to ensure infection control practices were followed for three of 33 sampled residents (R) (R19, R74, and R10). This deficient practice had the potential to increase the risk of infection due to cross-contamination of the residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for five rooms on one of three halls. These rooms contained dirty bathroom ceiling exhaust fan vent covers and a dirty, damaged Packaged Terminal Air Conditioner (PTAC) unit. The facility census was 82 residents. Observation on 2/27/2024 at 10:50 am and 2/28/2024 at 9:30 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. Observation on 2/27/2024 at 11:00 am and 2/28/2024 at 9:35 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. Observation on 2/27/2024 at 11:11 am and 2/28/2024 at 9:40 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow the care plan for two of 45 sampled Residents (R) (R27 and R41) by not assisting the residents with Activities of Daily Living (ADL's). Specifically, the facility failed to provide nail care as evidenced by long, broken, and jagged fingernails.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for two of 45 sampled Residents (R) (R27 and R41). Specifically, the facility failed to provide nail care for R27 and R41. This failure had the potential to affect the resident's comfort, body image and increase the risk for infection.

Inspectors wroteBased on observations, interviews, document reviews, and review of facility policy titled, Department Organization, undated, the facility failed to employ enough kitchen personnel to fully carry out the functions of the kitchen. Specifically, the facility failed to have enough staff to wash dishes for the 106 residents who ate meals from the kitchen, therefore, residents were using disposable dinnerware.

Inspectors wroteBased on observations, interviews, document reviews, review of Centers for Disease Control (CDC) guidelines, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 106 of 110 residents that received meals from the kitchen. Specifically, the facility failed to ensure proper hand hygiene practices were utilized during meal distribution, failed to ensure hot and cold foods were held and served at appropriate temperatures, failed to ensure cross contamination of ice from clothing, failed to ensure hair was covered in the food preparation area of the facility and failed to ensure food preparation equipment was properly maintained.

Inspectors wroteBased on observations, interviews, and review of the facility policies Personal Protective Equipment PPE and COVID-19 Visitation Guidelines, the facility failed to ensure that staff wore masks appropriately. Seven staff members were not wearing a mask appropriately covering the nose and mouth. This failure had the potential to affect all residents.

Inspectors wroteBased on observations, interviews, review of the facility's Center Contingency Plan, and review of the facility policy titled, Meal Service, the facility failed to treat residents with dignity by ensuring meals were not served on disposable dinnerware. This had the potential to affect 106 out of 110 residents served meal trays from the kitchen.

Inspectors wroteBased on observations, record review, interviews, and review of a facility policy titled, ADL (Activities of Daily Living) Plan of Care, the facility failed to ensure ADL care related to nail care and shaving was provided for three of four sampled residents (Resident (R) #55, R#73, and R#91) reviewed for ADL care.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Meal Service, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect 106 out of 110 residents served meals from the kitchen.

Inspectors wroteBased on observations, record reviews, interviews, and review of the facility policy Patient's Plan of Care, the facility failed to ensure the care plan for two of 25 residents (R) R#48 and R#74 was implemented to prevent falls from occurring and failed to ensure one of 25 resident care plans were developed for R#41 to address vision impairment.

Inspectors wroteBased on record review, interviews, and review of the facility policies Patient's Plan of Care and Fall Management, it was determined that the facility failed to ensure the care plan for one of 25 residents (R) R#48, reviewed for care planning was revised to prevent future falls from occurring.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled Moving A Patient Up in Bed, it was determined the facility failed to ensure one of one sampled resident (R) #90, received treatment and care in accordance with the resident's comprehensive person-centered care plan. Specifically, the facility failed to ensure R#90 maintained proper body alignment while in a geriatric chair (Geri-chair).

Inspectors wroteBased on observations, record reviews, interviews, and review of the facility policy, Fall Management, the facility failed to ensure that falls were thoroughly investigated, and appropriate interventions were put into place to prevent falls for two residents, Resident (R) #48 and R#78, of five residents reviewed for falls.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled, Pharmacy Services - Antimicrobial Stewardship Program Center Mission and Commitment Statement, the facility failed to implement antibiotic use protocols related the Antibiotic Stewardship Program for one resident (R) #101, of six sampled residents whose clinical records were reviewed for the use of unnecessary medications. Specially, R#101 had an order for antibiotics to be administered; however, the facility failed determine if antibiotics were necessary for the resident prior to beginning antibiotics.