Northwestern Healthcare Center

Inspectors wroteBased on closed medical record review, staff interviews, interviews with family, family friend, and home health aide, review of Emergency Medical Services (EMS) run report and call transcripts, review of the facility's Self-Reported Incident (SRI) and investigation, and review of facility policies, the facility failed to prevent an incident of neglect involving Resident #87. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 11:30 P.M. when Resident #87 complained of chest pain to Certified Nursing Assistant (CNA) #609 who reported the change to Registered Nurse (RN) #422. RN #422 then failed to timely identify and obtain treatment for Resident #87 following an acute change in condition. In addition, the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated timely at the time Resident #87 was found unresponsive (without vital signs). [...]

Inspectors wroteBased on closed record review, staff and family interview and policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #90 was provided adequate assistance during care to prevent a fall with major injury. Actual harm occurred 02/05/25 when Resident #90, who required substantial/maximal staff assistance with bed mobility (rolling left and right) and was dependent on staff for toileting sustained a fall from an elevated bed during the provision of care. As a result of the fall the resident suffered left and right femur fractures, a fibula fracture and a tibia fracture requiring hospitalization and medical intervention. This affected one resident (#90) of three residents reviewed for falls. The facility census was 81.

Inspectors wroteBased on observation, staff interviews, and review of the facility policy, the facility failed to ensure expired foods were disposed of timely. This had the potential to affect 79 residents who the facility identified receive meals from the kitchen, and Residents #6 and Resident #45 were ordered nothing-by-mouth. The facility census was 81.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to implement and maintain a comprehensive Quality Assurance Improvement Program (QAPI) program and plan to address care issues and/or concerns in the facility. This had the potential to affect all 81 residents who reside in the facility. The facility census was 81.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Quality Assurance (QA) meetings were held at least quarterly with the Medical Director present, to address care issues/concerns in the facility. This had the potential to affect all 81 residents who reside in the facility.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to perform hand hygiene between residents and after glove use during medication administration. This affected five residents (#51, #63 #76, #110, and #111) observed for medication administration. The facility census was 81.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to ensure the residents received quarterly statements for their resident funds account. This affected one (#54) of six residents reviewed for resident trust funds account. The facility identified 38 residents had resident funds account. The facility census was 81.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to notify each resident that received Medicaid benefits when their resident reached $200 less than the Supplemental Security Income (SSI) resource limit. This affected two residents (#28 and #45) of six residents reviewed for resident funds. The facility census was 81.

Inspectors wroteBased on observation, record review, resident and staff interviews, and facility policy review, the facility failed to ensure care plans were timely updated and care conferences were held quarterly with the resident and/or family. This affected two residents (#49 and #58) of three residents reviewed for care plans. The facility census was 81.

Inspectors wroteBased on observation, record review, resident and staff interviews, and facility policy review, the facility failed to ensure the residents received proper treatment and assistive devices to maintain hearing abilities. This affected one (#49) of one reviewed for ancillary services. The facility census was 81.

Inspectors wroteBased on record review, resident and staff interviews, and observation, the facility failed to ensure the residents received timely and proper treatments for foot care. This affected one (#49) one resident reviewed for podiatry. The facility census was 81.

Inspectors wroteBased on observation, staff interview and recipe review, the facility failed to prepare purees per standards of practice to ensure nutritional value. This had the potential to affect two residents (#32 and #37) who the facility identified to receive pureed meals at the facility. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to administer the facility to employ enough laundry staff to the meet the needs of the residents. This had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on review of facility documents and staff interview, the facility failed to ensure they had a transfer agreement with one ore more hospitals. This had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete personal laundry and return it to residents in a timely manner. This affected three of three residents (#49, #74, and #80) reviewed and had the potential to affect all 81 residents in the facility who had their laundry done by the facility. The family did the laundry for six residents (#2, #11, #22, #51, #55, #74). The facility census was 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange for an escort to an outside appointment for Resident #80, who at previous appointments had always had an escort. This affected one Resident of three residents reviewed for transportation arrangements. The facility census was 87. Findings Include: Review of the medical record for Resident #80 revealed an admission date of 03/30/23. Diagnoses included Parkinson's disease, legal blindness, glaucoma, and schizophrenia. Review of Resident #80's appointment orders revealed an escort needed for appointments scheduled for 09/24/24, 09/27/24, and 10/01/24. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #80 had intact cognition. Resident #80 had highly-impaired vision and used a wheelchair for mobility. Review of the nurse's note on 10/24/24 at 3:01 P.M. [...]

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to ensure Resident #89 was free from significant medication errors when Resident #89's admission orders were not timely transcribed, resulting in a delay in the resident receiving his ordered medications. This affected one Resident (#89) out of three residents reviewed for medication administration. The facility census was 87.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one Resident (#39) and had the potential to affect eight residents (Residents #16, # 28, #47, #55, 60, #65, #77, and #87) residing on the Back North Hall. The facility census was 87.

Inspectors wroteBased on observation of medication pass, staff interview, medical record review, review of manufacturer's instructions, review of medication card instructions and review of facility policy, the facility failed to maintain a medication error rate of less than five percent. The facility medication error rate was calculated to be 10.34 percent (%) and included three medication errors of 29 observed medication opportunities. This affected two residents (#58 and #75) of four residents observed for medication pass. The facility census was 96.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #46 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 08/20/24 when Resident #46, who was at risk for developing pressure ulcers, and was dependent on staff for bed mobility and incontinence care was identified to have new areas of in-house acquired skin impairment with no additional assessment or new treatment at that time. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure infection control practices were implement during incontinence care and high risk care activities. This affected two residents (Resident's #12 and #31) and had the potential to affect 18 residents (#1, #4, #9, #10, #12, #13, #16, #24, #31, #38, #43, #45, #49, #52, #57, #59, #67, #68) requiring enhanced barrier precautions.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #46's incontinence care was provided timely. This affected one resident (Resident #46) out of three residents reviewed for incontinence care. The facility census was 90.

Inspectors wroteBased on interview, record review, review of hospital records and facility policy the facility failed to ensure Resident #91's left knee contusion with fracture blisters, hematoma and effusion was evaluated, monitored, and treated timely. This affected one resident (Resident #91) out of three residents reviewed for wounds. The facility census was 90.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure care and services were provided to ensure Resident #46 was safely transferred and transported to an appointment, and failed to ensure fall interventions were implement to prevent Resident #76's from falling. This affected two residents (#46 and #76) of three residents reviewed for accident hazards. The facility census was 90.

Inspectors wroteBased on observation, closed medical record review, review of an emergency medical services run report, review of facility witness statements, review of the diet guide sheet and recipes, review of the facility's diet manual, review of employee disciplinary action and interviews, the facility failed to ensure residents with physician orders for mechanically altered diets were provided the correct texture food items to prevent choking and to meet their individual needs. This resulted in Immediate Jeopardy and actual harm/death on 04/23/24 during the dinner meal when Resident #91, who was ordered a Dysphagia Advanced diet, was edentulous and care planned for oral problems, was served a broccoli salad; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #87 was free from skin impairment. This affected one resident (Resident #87) out of three residents reviewed for wounds. The facility census was 85.

Inspectors wroteBased on observations and interviews the facility failed to ensure the residents could easily identify employees by their name and title on a badge violating the resident's right to dignity and respect in their home. This affected all six (Resident's #11, #20, #29, #35, #53 and #68) present at resident council and had the potential to affect all residents in the facility. The facility census was 89.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). Two errors were observed in 32 opportunities resulting in a 6.25 % medication error rate. This affected one (Resident #21) of eight residents observed for medication administration. The facility census was 89.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to maintain infection control during medication administration and ensure transmission-based precautions (TBP) were maintained for new admissions and readmissions. This affected two of two residents reviewed for TBP (Resident's #51 and #291) and one (Resident #50) of one resident observed for medication administration through a percutaneous endoscopic gastrostomy (PEG) tube. The facility census was 89.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure privacy curtains were cleaned and in sanitary condition. This affected one resident (Resident #70) observed for soiled privacy curtains. The facility census was 89.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents care plans were updated and revised to the meet the individual needs of its residents. This affected two residents (Resident #9, and Resident #62) of 44 residents whose care plans were reviewed. The facility census was 87.

Inspectors wroteBased on record review and interviews the facility failed to provide a complete discharge summary to Resident #91 prior to her discharge. This affected one of two residents reviewed for discharge. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's lost hearing aid was replaced in a timely manner. This affected one (Resident #9) of two (Resident's #18 and #61) with hearing aids. The facility census was 89.