North End Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 9, 2025

  Based on record review and interview, the facility failed to immediately perform cardiopulmonary resuscitation (CPR) according to professional standards of care for one Resident (#89), who was a full code, out of a total sample of 26 residents. Specifically, after Resident #89 was found with no pulse the nurse on duty, whose CPR certification had expired, left the Resident in a room with a Certified Nursing Aide (CNA), while he retrieved life saving materials and called 911, delaying life saving CPR measures for Resident #89. Findings include: Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. […]

• Immediate jeopardy, isolatedF726May 9, 2025

  Based on record review and interview, the facility failed to ensure the assigned nurse was competent to perform Cardiopulmonary Resuscitation (CPR) on one Resident (#89), who was a full code, after he/she was found unresponsive, out of a total sample of 26 residents. Findings include: Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest. […]

• Actual harm, patternF686Apr 25, 2022

  Based on observation, record review, and interview, the facility failed to ensure residents received appropriate treatments and interventions to prevent the development and deterioration of pressure injuries for 3 residents (#75, #9 and #27) out of a total of 29 sampled Residents. Findings include: 1. For Resident #75, the facility failed to A) identify the deterioration of an existing pressure ulcer, B) failed to ensure wound treatments were implemented correctly and timely, C) failed to ensure the use of a wound vac (a device used to help treat pressure ulcers) was monitored and used with valid physician orders, and D) failed to ensure wound treatments were completed as ordered. Subsequently, Resident #75's existing pressure ulcers deteriorated and new pressure ulcers developed. […]

• Actual harm, isolatedF692Jul 13, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for nutritional decline, the Facility failed to ensure based on his/her comprehensive assessment, that he/she maintained acceptable parameters of nutritional status, when he/she experienced a severe undesired significant weight loss and required the addition of protein supplements due to malnutrition. Findings include: The Facility Policy titled Nutritional Assessment, undated, indicated the dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframe's) and as indicated by a change in condition that places the resident at… […]

• Actual harm, isolatedF684Apr 25, 2022

  Based on record review and interview, the facility failed to complete wound treatments as ordered by a physician for 1 Resident (#75) out of a 29 sampled Residents. Subsequently, Resident #75's existing pressure ulcer deteriorated. Findings include: Resident #75 was admitted to the facility in October 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's most recent Minimum Data Set Assessment indicated he/she was moderately cognitively impaired and required physical assistance with eating, transfers, bathing and dressing. During an interview with Nurse #1 on 4/21/22 at 11:03 A.M., she said that it was possible that facility staff were not performing treatments as ordered for Resident #75. […]