North Ridge Health and Rehab

In the surveyor’s words

From the most serious findings on record at North Ridge Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Mar 7, 2025

  Based on interview and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's paper chart, electronic medical record (EMR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the resident's wishes would be followed in the event of a respiratory or cardiac arrest. This resulted in immediate jeopardy for 1 of 49 residents (R43) whose code status was not accurately documented and was reviewed for advanced directives. […]

• Immediate jeopardy, isolatedF600Mar 5, 2021

  Based on interview and document review, the facility failed to ensure residents were free from abuse for 2 of 3 (R6 and R1) residents reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R5 was reportedly masturbating in front of a female resident (R7), then was reported to masturbate in front of another resident (R6), and then was found leaving R1's room whom had her pants down, and a [MEDICATION(S)] like substance on her body. The facility failed to recognize sexual abuse and implement interventions to protect other residents from potential abuse. The IJ began on 2/26/21, when R5 was reportedly masturbating in front of a female resident and the facility did not implement interventions. […]

• Actual harm, isolatedF690Dec 16, 2022

  Based on observation, interview and document review, the facility failed monitor, assess, and identify interventions to reduce the risk of catheter related complications for 1 of 3 residents (R1) reviewed for catheter care when R1's penis eroded from the indwelling catheter. R1's catheter was placed on 9/30/22, R1 complained of penile pain associated with the indwelling catheter 11/2/22 and 11/23/22, then was not evaluated by the facility until 11/29/22 identifying erosion of the penile shaft. Findings include: R1's admission Minimum Data Sheet (MDS) dated [DATE], identified intact cognition. R1 required extensive assistance by two nursing staff to move in bed, transfer, dress, and toilet. […]

• No harm, potential for more than minimal, widespreadF919Mar 7, 2025

  Based on observation and interview, the facility failed to ensure a complete wireless call system in which staff were provided with functioning devices alerting them to call light activation in their possession. This had the potential to affect all 250 residents at the facility. Findings include: During an observation on 3/5/25 at 2:35 p.m., it was noted there were no call light indicators above the resident rooms on the East side in hallways 500, 600, or 700. At about the middle of each hall there were two scrolling kiosks of about two feet in length and five inches tall, suspended from the ceiling in facing opposite ways. The kiosk displayed the resident room and bed number of the resident who had activated their call light. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure clean dishes were stored in a manner to minimize risk of environmental contamination. The facility also failed to ensure resident meals were delivered under sanitary conditions. This had the ability to affect all 71 residents residing on 2 West (W). Furthermore, the facility failed to ensure refrigerated foods were properly labeled and stored and out of range refrigerator temperatures were acted upon. This had the ability to affect all 171 residents who receive food from the kitchen. Findings include: Clean storage and meal delivery During an observation on 9/12/22, at 9:44 p.m. the 2W kitchenette and dining area was not in use and staff were not present. […]