Norridge Gardens

In the surveyor’s words

From the most serious findings on record at Norridge Gardens, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 11, 2024

  Based on observations, interviews and record reviews, the facility failed to supervise a resident that ingested another resident's medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for supervision with medication. The findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/2023 at 1:13 AM. Soon after delivery, V19 left the medication on top of V20's (RN) medication cart which was inside a locked unit. V19 did not inform V20 of the delivery. […]

• Actual harm, isolatedF761Jan 11, 2024

  Based on interview and record review, the facility failed to safeguard and properly store a medication that led to a confused resident ingesting that medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for medication storage. Findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred on 12/17/2023 between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/23 at 1:13 AM. Soon after delivery, V19 left the medications on top of V20's (RN) medication cart which was inside a locked unit without informing V20 of the delivery. […]

• Actual harm, isolatedF689May 10, 2023

  Based on interview and record review, the facility failed to assist a resident to the toilet, resulting in the resident transferring herself and falling. The fall resulted in a fractured left hip which required surgical repair. This applies to 1 of 3 (R4) residents reviewed for falls. Findings include: On May 9, 2023, at 10:03 AM, R4 was observed in bed with a surgical incision on her left hip. The hospital records dated April 27, 2023, at 1:31 PM show a history and physical documenting the following: [R4] is complaining of [left] hip pain after the fall. In the ED [Emergency Department], she is noted to have [left] hip femoral neck fracture. Plan is for OR (Operating Room). On May 9, 2023, at 10:40 AM, V16 (RN/Registered Nurse) said she was assigned to R4 on April 26, 2023. […]

• Actual harm, isolatedF690Jan 27, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident with a current UTI (Urinary Tract Infection) had orders for an indwelling catheter and failed to change the indwelling catheter. This resulted in R26 experiencing chronic UTIs with the need for IV (intravenous) antibiotic treatment. The facility failed to provide incontinence care in a manner to meet professional standards. These failures apply to 2 of 7 residents (R26, R95) reviewed for catheter and bladder care in the sample of 35. The findings include: 1. On 1/24/23 at 11:09 AM, R26 was lying in bed with an IV antibiotic connected to the IV site in his right hand. R26 had an indwelling catheter. The tubing of the catheter was hazy, and it was difficult to visualize the urine in the tubing. […]

• Actual harm, isolatedF692Jan 27, 2023

  Based on observation, interview, and record review the facility failed to prevent severe unplanned weight loss, failed to ensure weights were performed as ordered, and failed to implement interventions after a significant weight loss for 6 of 7 residents (R205, R56, R143, R99, R124, R35) reviewed for nutrition in the sample of 35. These failures resulted in R205 sustaining a severe 20.33% weight loss over 6 months and R56 sustaining a severe 16.18% weight loss over 2 months. The findings include: 1. R205's face sheet printed on 1/26/23 showed diagnoses including dementia with behavior disturbance, anxiety, depressive disorder, and psychosis. R205's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance needed for setup during eating. […]