North Bank Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at North Bank Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802Dec 9, 2021

  Based on observations, record reviews and interviews, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This had the potential to negatively impact all residents who received meals from the kitchen. The findings include: On 12/06/21 at 2:15 PM, observations were made of the low temperature dishwasher while being used by a dietary staff member. The dishwasher was observed at a temperature of 115 °F. Two more wash cycles were observed and the temperature never rose above 118 °F. Dietary Staff Member (DSM) I reported the dishwasher temperature should be 120 to 125° F. She was asked what temperature the dishwasher was at now, and she replied, I don't know, I have to get my glasses. […]

• No harm, potential for more than minimal, patternF695Aug 5, 2026

  Based on observation, interview, and record review, the facility failed to ensure that respiratory care services, including oxygen therapy, were provided in accordance with physician orders, professional standards of practice, and the residents' assessed needs for 5 of 9 sampled residents (Residents #4, #5, #7, #8, and #9). The facility did not ensure oxygen was administered at the ordered flow rate, tubing and humidifiers were dated and maintained, orders were accurately entered and followed, care plans reflected actual respiratory needs, or that equipment was appropriately functioning. This failure had the potential to place residents at risk for inadequate oxygenation, respiratory decline, or other avoidable complications. The findings include: 1. […]

• No harm, potential for more than minimal, patternF880Sep 25, 2025

  Based on observations, staff interviews, and a review of facility documentation, the facility failed to 1) Follow proper environmental cleaning and disinfection protocols for a resident shared bathroom (room [ROOM NUMBER]) for three consecutive days, 2) Properly dispose of used razors left accessible in two resident rooms (rooms [ROOM NUMBERS]), 3) Properly clean and disinfect identified feces in a resident bathroom shower (room [ROOM NUMBER]), 4) Use appropriate infection control practices by staff failing to don appropriate personal protective equipment (PPE) and practice proper hand hygiene when administering medication through a gastrostomy tube (g-tube - feeding tube) for one of seven residents with g-tubes receiving medication. […]

• No harm, potential for more than minimal, patternF759Oct 12, 2023

  Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less based on four errors out of 27 opportunities for error, resulting in an error rate of 14.81% and involving three (Residents #66, #61, and #53) of seven residents observed during medication administration. Failure to administer medications correctly as ordered could result to side effects with serious harm to the residents. The findings include: During medication administration observation on 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting point-of-care blood glucose testing for Resident #66. She obtained the resident's blood glucose level of 182 milligrams/deciliter (mg/dl). […]

• No harm, potential for more than minimal, patternF880Oct 12, 2023

  Based on observation, interview, and a review of the facility's policies and procedures, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during point-of-care testing for two (Residents #66 and #61) of two residents observed during point-of-care testing, out of seven residents observed during medication administration. Failure to adhere to infection control standards during point-of-care testing poses a risk to residents of acquiring communicable diseases. The findings include: On 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting blood glucose testing for Resident# 66. […]