Northridge Village

In the surveyor’s words

From the most serious findings on record at Northridge Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Oct 20, 2022

  I. Based on clinical record review, family, staff and physician interviews, and facility competency and policy review, the nursing staff failed to adequately assess a resident, provide timely interventions, and notify the physician of a resident's change in condition for 1 of 13 residents reviewed (Resident #34). The nursing staff's failure to adequately assess, intervene, and notify the resident's physician resulted in the nursing staff failing to take actions to address Resident #34's urinary tract infection, which resulted in Resident #34's hospitalization and later death due to the systemic spread of the urinary tract infection. The facility's administrative staff identified a census of 37 residents. Findings include: 1. […]

• Actual harm, isolatedF689Jun 20, 2024

  Based on clinical record review, staff interviews, and review of the facility's self-report, the facility failed to ensure the safety of a resident in the environment for 1 of 3 residents reviewed (Resident #1). The record review revealed Resident #1 required assistance of one staff with a gait belt for ambulation and transfer. On 4/3/24 at approximated 8:15 AM, as Staff A, Certified Nursing Assistant (CNA), assisted Resident #1 to ambulate with a gait belt, they said they needed to sit down in a wheelchair. When Staff A let go of the gait belt, Resident #1 lost their balance and fell down on the floor on their left side, resulting in a hip fracture. […]

• Actual harm, isolatedF580Oct 20, 2022

  Based on record review, staff interviews, and policy review, the facility staff failed to notify the physician for 1 of 12 residents who had a change of condition reviewed (Resident #34). Review of the health record reveled Resident #34 exhibited a change of urinary symptoms and the nursing staff failed to notify the nurse practitioner, which led to a delay in treatment. The facility reported a census of 37 residents. Findings include: 1. The resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had a brief interview for mental status (BIMS) score of 15, which indicated an intact cognition. […]

• Actual harm, isolatedF689Nov 2, 2021

  Based on record and policy review, and staff interviews, the facility failed to ensure one (1) of five (5) residents received adequate supervision to protect against hazards in the environment. Resident #1 required assistance of two staff with a pivot disc and a gait belt for transfer. On [DATE], one nursing staff person assisted Resident #1 to transfer without a gait belt. The resident's legs gave out and staff lowered the resident to the floor. The resident sustained a right [CONDITION(S)], was a high risk surgical candidate, underwent surgery and died from complications. […]

• No harm, potential for more than minimal, isolatedF656Jan 9, 2025

  Based on clinical record review, staff interviews and policy review, the facility failed to develop and implement a comprehensive person-centered Care Plan for 2 of 11 residents reviewed for Care Plans (Resident #1 and Resident #35). The facility reported a census of 36 residents. Findings include: 1. Resident #35's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of depression, fractures, and other multiple trauma. The MDS reflected Resident #8 took an antidepressant during the lookback period. Resident #35's Medical Diagnoses reviewed on 1/8/25 listed a diagnosis of depression, unspecified. […]