Inspection Reports for North Ridge Health and Rehabilitation Center

The complaint investigation found that the restraint mitt was used for discipline or convenience rather than medical necessity. The restraint was not ordered by a practitioner, and no assessments or care plan updates were documented. The Director of Nursing and Nurse Practitioner confirmed the restraint was inappropriate and removed it.

The facility failed to ensure freedom from physical restraints for resident R49, who was found wearing a restraint mitt without an order, assessment, or care plan. Staff interviews and record reviews confirmed the restraint was used to prevent the resident from pulling on a feeding tube, but the restraint was not medically justified or properly documented.

The facility was found deficient in multiple areas including failure to ensure protective placement for a resident with a legal guardian, incomplete PASRR Level II screening for a resident with a new mental illness diagnosis, inconsistent monitoring of a WanderGuard device, incomplete dialysis assessments and documentation, lack of proper medication self-administration assessments, and unsafe food storage and preparation practices.

The facility failed to ensure accurate medication administration for 4 of 9 sampled residents and did not consistently reconcile narcotic medications, resulting in missing controlled substance count signatures across multiple shifts.

The facility failed to ensure that one resident with a stage 3 pressure injury received appropriate wound care according to physician orders, resulting in wound infection requiring intravenous antibiotics and surgical debridement. The wound care management was inconsistent, including use of incorrect dressings and failure to properly cleanse wounds, contributing to worsening of the wound condition.

The complaint investigation included failure to notify a resident's representative of a change in condition, inadequate supervision leading to elopement, unsafe food handling practices, and infection prevention and control deficiencies. Immediate jeopardy was identified related to the elopement incident but was removed after corrective actions were implemented.

The facility failed to notify a resident's representative of a significant change in condition, failed to provide adequate supervision to prevent elopement resulting in immediate jeopardy, did not ensure safe and sanitary food handling practices including proper hair restraints, hand hygiene, and food temperature control, and failed to maintain an effective infection prevention and control program including proper use of PPE and hand hygiene during resident care.

The facility was found deficient in multiple areas including failure to follow advance directive wishes and guardianship orders, incomplete medication self-administration assessments, inadequate call light accessibility, lack of advance directives documentation, failure to provide proper transfer and bed hold notices, inadequate pressure ulcer care, unsafe smoking assessments, incomplete dialysis vital signs and weight documentation, expired medications and unlocked medication carts, poor infection control practices, and inaccurate staffing data submission to CMS.

The complaint investigation focused on concerns about delayed care and notification for a resident with a change of condition, missing weights for residents with feeding tubes, improper food preparation and serving, unsafe food temperatures, and poor hand hygiene and food handling practices.

The facility failed to provide appropriate care and timely notification for a resident with a change of condition, did not obtain ordered weights for residents with feeding tubes, did not follow pureed food recipes or serving sizes, served pasta salad at unsafe temperatures, and did not ensure proper hand hygiene and sanitary food handling practices in the kitchen.

The facility failed to serve milk at a safe and appetizing temperature, with milk measured at 53.6 degrees Fahrenheit, exceeding the recommended 32-40 degrees. Additionally, staff did not consistently perform appropriate hand hygiene during food preparation, increasing the risk of foodborne illness.

The complaint investigation found that the facility did not substantiate proper monitoring and documentation for Resident 2 after a change in condition, leading to hospitalization for septic shock. The resident was not assessed by nursing staff from 10/11/23 through 10/15/23 or on 10/17/23, and was not included in the facility's 24-hour monitoring reports during this period.

The facility did not ensure proper monitoring and documentation of a resident's edema and weight after a physician's orders, resulting in missed assessments and failure to obtain a urinalysis. The resident was hospitalized with septic shock related to a urinary tract infection and pneumonia. Nursing staff failed to include the resident in 24-hour monitoring reports and did not assess the resident during critical days of condition changes.

The complaint was substantiated for Resident 4 (R4). R4 reported that CNA-C did not treat residents respectfully and failed to change a Chux Pad properly. R4 filed a grievance with the Director of Nursing (DON-B), who assured R4 that CNA-C would not provide care. However, CNA-C continued to care for R4 with the same attitude. DON-B did not follow up adequately, and documentation was lacking.

The facility failed to ensure that a grievance filed by R4 was properly documented, investigated, and resolved. Despite assurances that CNA-C would not care for R4, CNA-C continued to provide care with the same negative attitude. The facility's grievance policy was not fully followed, and documentation and follow-up were insufficient.

The facility was found deficient in multiple areas including failure to complete required PASRR screenings for residents with mental disorders, incomplete baseline care plans for new admissions, inadequate assistance with activities of daily living such as weekly showers, inconsistent nutritional monitoring including weight checks and feeding tube rates, lack of monitoring for side effects of high-risk medications, insufficient food service management qualifications, improper food portioning and preparation, unsanitary food storage and preparation practices, failure to maintain proper food temperatures, and inadequate infection prevention and control practices including improper glove use and hand hygiene.