North Star Ranch Rehabilitation and Healthcare Cen

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 5 (Resident #25, Resident #22, Resident #48, Resident #32, and Resident #15) of 53 residents reviewed for accidents and hazards. 1.The facility failed to ensure Resident #25 did not receive a cigarette burn on 08/24/24. 2.The facility did not ensure Resident #22, who was assessed as an unsafe smoker, signed out to smoke in an unsafe area on 04/21/25 and kept his cigarettes, vapor and lighter in his possession. 3.The facility did not ensure that Resident #48, who was assessed as a safe smoker, did not sign out of the facility to smoke on the side of a residential street on 04/22/25. […]

• Immediate jeopardy, isolatedF689Feb 27, 2025

  Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's bed was locked while providing care resulting in a fall with fractures to the orbital floor (a break to the thin, bony plate that forms the bottom of the eye socket) and cervical spine on 1/30/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/26/25 at 12:00 p.m. […]

• Immediate jeopardy, isolatedF684Jan 12, 2024

  Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility failed to provide an in-house wound evaluation for treatment of Resident #1's left foot declining condition. The facility failed to provide an evaluation to ensure Resident #1's mental health did not complicate her physical health. The facility failed to provide a recent to provide psychiatric services when Resident #1's behaviors continued. The facility failed to accurately assess Resident #1's left foot wound. […]

• Immediate jeopardy, isolatedF740Jan 12, 2024

  Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to have Resident #1 evaluated for decision making capacity. The facility failed to provide a psychological evaluation to determine if Resident #1 was a harm to herself. The facility failed to re-offer psychiatric services since 8/2023 for Resident #1. The facility failed to develop interventions to address the resident's acute schizophrenic behaviors. The facility failed to implement licensed social services to provide crises support, and coordination with the healthcare team. […]

• Actual harm, isolatedF689Jan 12, 2024

  Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 3 (Resident #2) residents reviewed for accidents. The facility failed to ensure CNA F used two-person assistance to provide incontinent care for Resident #2 which resulted in a fall with injury. This failure could place residents at risk of injuries, falls and hospitalization s. Findings include: Record review of Order Summary Report dated 01/12/2024 indicated Resident #2 was a [AGE] year-old male, with an admission to the facility on [DATE] with diagnoses including dementia (decline in cognitive abilities that impacts a person's abilities to perform everyday activities), myocardial infarction (a blockage of blood flow to the heart muscle),… […]