Northridge Rehabilitation and Care Center

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident identified as being at risk for falls received timely and appropriate assistance during showering resulting in the resident experiencing a fall. This affected one (#16) of three residents reviewed for falls. The facility census was 68.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure medications were given as prescribed. This affected two (#12 and #16) of three residents reviewed for medications. The facility census was 68.

Inspectors wroteBased on observation, resident and staff interviews, and policy review, the facility failed to ensure food was served at safe and palatable temperatures to the residents. This had the potential to affect 66 residents who received food from the kitchen. Two residents were nothing by mouth. The facility census was 68.

Inspectors wroteBased on observation, staff interview, medical record review, and review of the facility policy, the facility failed to maintain infection control practices after providing resident care. This had the potential to affect all 69 residents residing at the facility. The facility census was 69.

Inspectors wroteBased on observation, resident and staff interview, medical record review, review of a police report, review of facility investigation documents, and policy review, the facility failed to ensure a resident's change in condition was reported to the physician in a timely manner. This affected two (#23 and #20) of four residents reviewed for assessments and monitoring. The census was 69.

Inspectors wroteBased on medical record review, incident file review, and staff interview, the facility failed to ensure comprehensive resident centered care plans were developed to address resident medical and psychosocial needs. This affected one (#70) of four residents reviewed for care plans. The facility census was 69.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure dependent residents received timely care and services from staff to provide activities of daily living (ADLs). This affected one (#38) of three residents reviewed for ADLs care. The facility census was 69.

Inspectors wroteBased on observation, staff interview, medical record review, review of a police report, and review of facility investigation documents, the facility failed to ensure a resident (#70) was properly monitored for behaviors regarding drug use following know usage in the facility and failed to timely assess a resident (#23) following exposure to illicit substances. This affected two (#23 and #70) of four residents reviewed for assessments and monitoring. The census was 69.

Inspectors wroteBased on observation, staff interview, medical record review, and review of a facility policy, the facility failed to assure residents received supplemental oxygen per physicians orders. This affected one (#72) of three residents reviewed for oxygen therapy. The facility census was 69.

Inspectors wroteBased on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered per the physicians orders. This affected two (#17 and #30) of 14 residents identified by the facility with orders for insulin injections via insulin pen. The facility census was 69.

Inspectors wroteBased on observation, resident, family, and staff interview, record review, and review of the facility assessment, the facility failed to provide sufficient staffing to consistently meet the resident's needs. This affected three (Residents #55, #181, and #182) and had the potential to affect all 74 residents residing at the facility.

Inspectors wroteBased on record review, review of personnel job descriptions, review of personnel files, review of the facility's infection control program, resident, staff, and family interview, and interview with the local health department (LHD), the administration team lacked involvement to ensure staff and resident reports of staff mistreatment were not dismissed before investigating the allegations, did not identify an issue with the resident's medical records being accurate and factual, and did not ensure adequate staffing was maintained to meet the needs of their residents and according the facility's assessment. Administration did not ensure routine care conferences were being held routinely with the residents and resident representatives and did not ensure routine written notices of transfer and bed hold notices were completed upon the resident's transfer to the hospital. [...]

Inspectors wroteBased on review of the medical record, review of a COVID-19 outbreak log, review of staffing schedules, review of staff timecards, review of the staff call-off log, staff and resident interview, observation, interview with the Local Health Department (LHD), review of the Centers for Disease Control and Prevention (CDC) infection control guidance, and policy review, the facility failed to implement an effective and recommended infection control practices, including timely contact tracing to identify close contacts of COVID-19 positive residents and staff, timely reporting of a COVID-19 outbreak to the LHD, and a system to ensure all staff and residents were tested for COVID-19 per CDC guidelines and facility policy to prevent the potential spread of COVID-19 to vulnerable residents within the facility. [...]

Inspectors wroteBased on review of resident immunizations, review of personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. The facility census was 74.

Inspectors wroteBased on resident and staff interview, record review, and review of the facility policy, the facility failed to have routine/scheduled care plan meetings for the residents and/or resident representative in 2024. This affected one (Resident #51) of one resident reviewed for care plan meetings. The facility identified all residents residing at the facility with the exception of 18 residents admitted after November 2024 (Residents #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have care conferences in 2024. The facility census was 74.

Inspectors wroteBased on observations, resident, family, and staff interviews, and record review, the facility failed to ensure medical records were accurate and factual. This affected eight (Residents #26, #35, #38, #53, #53, #55, #57, and #177) of 27 residents medical records reviewed during the annual survey. The facility census was 74.

Inspectors wroteBased on medical record review, and resident and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (Resident #13 and #74) of four residents reviewed for dignity. The facility census was 74.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure all residents' call lights were within reach. This affected three (Residents #14, #34, and #42) of 74 residents reviewed for call lights within reach. The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview and policy review, the facility failed to ensure a resident's family was notified of a resident's decline in condition. This affected one (#178) of four residents reviewed for change in condition. The facility census was 74.

Inspectors wroteBased on staff interview, record review, and review of the facility policy, the facility failed to ensure a care plan was completed for Resident #61 to include depression, anxiety, and the use of psychotropic medications. This affected one (Resident #61) of 27 residents reviewed for care plans. The facility census was 74.

Inspectors wroteBased on resident and staff interview, record review, and review of the facility policy the facility failed to ensure a resident who required assistance from staff with activities of daily living received the care and services with bathing/showers. This affected one (Resident #182) of three residents reviewed for bathing/showers. The facility census was 74.

Inspectors wroteBased on observation, family and staff interview, record review, and review of the facility policy, the facility failed to ensure physician ordered compression socks were implemented for Resident #55 and failed to timely provide care and treatment to treat a resident's excessive sweating causing skin issues. This affected two (Residents #54 and #55) of seven residents reviewed for care and services. The facility census was 74.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to ensure a resident received the appropriate treatment and services to maintain/improve mobility according to physician orders. This affected one (Resident #26) of one resident reviewed for range of motion. The facility census was 74.

Inspectors wroteBased on observation, staff interview, record review and review of the facility policy, the facility failed to prevent an avoidable fall with minor injury for Resident #54, failed to ensure fall interventions were in place for Resident #54 who was at a fall risk, and did not complete a thorough fall investigation into Resident #173' fall. This affected two (Residents #54 and #173) of three residents reviewed for falls. The facility census was 74.

Inspectors wroteBased on record review, observations, resident, family, and staff interview, and policy review, the facility failed to ensure the resident's indwelling catheter tubing was secured to the resident to prevent dislodgement of the urinary catheter. Additionally, the facility failed to ensure residents receive timely incontinence care. This affected two (Resident #5 and #47) of three residents reviewed for indwelling catheters and two (Residents #55 and #181) of three residents reviewed for incontinence care. The facility identified seven residents who have an indwelling catheters. The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure residents on psychotropic medications were monitored for adverse consequences and behaviors were routinely monitored. This affected three (Residents #13, #42, and #61) of five residents reviewed for unnecessary medications. The facility identified 48 residents receiving psychotropic medications. The facility census was 74.

Inspectors wroteBased on record review, observation, staff interview, review of Medscape guidance, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #30) of five residents reviewed for medication administration. The facility identified 14 residents who receive insulin via a pen-injector. The facility census was 74.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure all medications were stored appropriately and residents were watched when taking medications. This affected two of sevens (Resident #24 and #181) for medication storage. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were provided a written notice of transfer/discharge when sent to the hospital. This affected four (#44, #46, #76, and #78) of four residents reviewed for transfer/discharge. The facility identified 32 residents who were discharged to the hospital since 05/2024. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were provided a notice of bed hold policy when the resident was sent to the hospital. This affected four (#44, #46, #76, and #78) of four residents reviewed for transfer/discharge. The facility identified 32 residents who were discharged to the hospital since 05/2024. The facility census was 74.

Inspectors wroteBased on record review and staff and resident interviews the facility failed to ensure narcotic pain medication was available for administration. This affected one (#32) of the three residents reviewed for receiving narcotic pain relief. The facility identified 28 residents receiving narcotic pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone five milligram (mg) every four hours as needed (PRN) and an order to administer cyclobenzaprine 10 mg PRN for spasms. [...]

Inspectors wroteBased on record review, staff interview and review of facility policy, the facility failed to ensure a narcotic pain medication was accurately documented in the resident's Medication Administration Record (MAR). This affected one (#27) of three residents reviewed for pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone 5 milligram (mg) every four hours as needed (PRN). [...]

Inspectors wroteBased on observation, staff interviews and review of facility policy, the facility failed to ensure resident call lights were in reach of residents. This affected two (#32 and #69) of the three residents reviewed for call lights. The facility census was 80. Finding Include: 1)Review of the medical record for Resident #32 revealed an admission date of 01/18/24. Diagnoses included acute respiratory failure, paraplegia, traumatic brain injury (TBI), epilepsy, and type II diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/24, revealed Resident #32 had intact cognition and was dependent on staff for bed mobility, transfers and hygiene. Review of Resident #32's Care Plan dated 05/09/24 revealed the resident required assistance for activities of daily living (ADLs) related to immobility. Intervention included to keep the call light in reach. [...]

Inspectors wroteBased on medical record review, interview and review of policy the facility failed to ensure residents were invited to participate in care conference meetings regarding their care. This affected two of two residents (#20, #56) reviewed for care planning. The facility census was 87.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, the facility failed to ensure skin assessments were completed accurately and the facility failed to follow physician orders for oxygen administration. This affected one of one resident (#45) reviewed for skin assessments and oxygen administration. The facility census was 87. Findings Include: 1. Review of Resident #45 medical records identified Resident #45 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, chronic respiratory failure with hypoxia ,legal blindness, and personal history of traumatic brain injury. [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to administer tube feeding formula according to directions for use. This affected one of two residents (#78) reviewed for enteral tube feedings. The facility census was 87.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident's medications were kept secured against unauthorized access. This affected one of one resident (#50) reviewed for medication administration. The facility census was 87. Findings Include: Record review revealed Resident #50 was admitted into the facility on [DATE] with diagnoses of arteriosclerotic heart disease, heart failure, benign prostatic hyperpiesia with lower urinary tract symptoms, muscle weakness, difficulty in walking. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required moderate assistance from staff to aide in completing his activities of daily living. Review of the Medication Administration Policy (dated 08/22/22) stated under number 15: [...]

Inspectors wroteBased on medical records review, facility policy review and staff interview, revealed the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was current and up to date. This affected two (#28 and #54) of two residents reviewed for PASARR. The facility census was 75.

Inspectors wroteBased on medical record, staff and resident interviews and review of facility policy revealed the facility failed to provide showers per resident preferences. This affected two (#53 of #67) three of residents reviewed for Activities of Daily Living. The facility census was 75.

Inspectors wroteBased on record review, observations, staff interview and review of the facility policy, the facility failed to ensure an anchoring device for the Foley catheter was implemented to prevent accidental pain or injury from excessive tension and/or removal of a Foley catheter. This affected one (#41) of one resident reviewed for catheter care. The facility identified 11 residents with catheters. The facility census was 75. Findings Include: Review of Resident #41's medical record revealed the resident was admitted on [DATE]. Diagnoses included cerebral infarction, acute respiratory failure with hypoxia, tracheostomy, hypertension, and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed extensive assist of two person for bed mobility and has an indwelling Foley catheter. [...]