Northern Pines Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Northern Pines Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 21, 2024

  Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards by failing to effectively use a fall prevention program, root cause analysis, identify and implement appropriate interventions, and ensure staff used the interventions appropriately, for 3 (#s 7, 25, and 27) of 17 sampled residents. The on-going failure led to resident #25 sustaining a head laceration, requiring staples and an overnight stay in the hospital; resident #7 sustaining a head laceration requiring staples, a hip hematoma, and bruising on the left temple; and resident #27 sustaining a hematoma above the left eye and bloody nose. […]

• Actual harm, isolatedF692Nov 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident was weighed after an illness and hospitalization , for the identification of weight changes. This deficient practice delayed the identification of the resident's severe weight loss, for 1 (#5) of 17 sampled residents. Findings include: Review of resident #5's nursing progress notes, dated October 2023 - November 2023, showed the resident had been very ill for several weeks with Covid-19. Review of resident #5's hospital summary, dated 11/9/23-11/13/23, showed resident #5 had been admitted for UTI, Atypical Pneumonia, Failure to Thrive, and Anemia. Her weight on her 11/9/23 hospital admission was 123 lbs. […]

• Actual harm, isolatedF755Nov 20, 2023

  Based on interview and record review, the facility failed ensure adequate monitoring, glucose administration, and insulin parameters were in place for diabetic residents for 1 (#27) of 1 sampled resident. This deficient practice had the potential to affect any resident receiving insulin. During observations on 11/18/23 - 11/19/23, resident #27 was not observed to get out of bed or join any of the meals. Trays left at her bedside went untouched. During an observation and interview on 11/19/23 at 4:42 p.m., resident #27 was lying in bed and stated she hadn't had much to eat and was very sleepy. Review of resident #27's MAR, dated November 2023, showed she had an order for Blood Glucose AC and HS before meals and at bedtime related to .Diabetes mellitus with hyperosmolarity with coma. […]

• No harm, potential for more than minimal, widespreadF801Nov 21, 2024

  Based on interview and record review, the facility failed to ensure the director of food and nutrition services met the education qualifications required by CMS for a food service director, which increased the risk of residents being affected negatively since the director provided oversight for the entire dietary department. Findings include: During an interview on 11/19/24 at 12:13 p.m., staff member I stated staff member B told him to complete the first eight hour course of training and not to worry about the 16 hour training course until later. During an interview on 11/20/24 at 8:39 a.m., staff member D stated no policies specific to the dietary manager training requirements were available, and the facility used the CMS guidelines. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based on observation, interview, and record review, the facility staff failed to serve food in accordance with professional standards for food service safety, by not wearing hairnets, while in food service areas. Failure to uphold food safety may affect any resident at the facility. Findings include: During an observation on 11/18/24 at 2:51 p.m., staff member O had no hairnet on while walking through the kitchen while the cook was making meatballs. Staff member J was not wearing a hairnet while walking through the kitchen and working on stocking directly next to the prep table, where the cook was preparing meatballs. During an observation on 11/18/24 at 5:12 p.m., staff member J was prepping meal trays (for another location), and was not wearing a hairnet. […]