Northvine Postacute Care

In the surveyor’s words

From the most serious findings on record at Northvine Postacute Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF921Apr 4, 2025

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 57 out of 59 residents who received food from the facility's kitchen, when:1. a grease trap (a plumbing device, type of drain, intended to capture fats, oils and grease from wastewater), located in the dishwashing area under the two-compartment sink, was not maintained in good repair and caused wastewater (includes substances such as food scraps, oils, soaps and chemicals) to back-up on to the kitchen floor. This occurred while a County Department of Health Services (CDHS) Inspector was present on 3/18/25.2. […]

• Immediate jeopardy, patternF835Jun 9, 2023

  46132 Based on observation interview and record review, the facility failed to: 1. Have a consistent leadership of an Administrator, DON (Director of Nursing), and DSD (Director of Staff Development), which led to the lack of training for the nursing staff for both the Licensed Nurses and the Certified Nursing Assistants (CNAs). These failures had the potential for the nursing staff's inability to provide accurate assessments and safe provisions of care to the residents to ensure residents received high quality of care and effective care was being delivered. 2. […]

• Actual harm, isolatedF658Jul 28, 2025

  Based on interview and record review, the facility failed to meet professional standards of nursing care when one resident (Resident 1) of three sampled residents did not have documented weekly skin assessments in their medical chart and wound care treatments were not implemented to Resident 1's right great toe.This failure resulted in the development of infection and maggots in Resident 1's right great toe, which required hospitalization and subsequent amputation to his right great toe. […]

• Actual harm, isolatedF687Jul 28, 2025

  A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (a condition characterized by paralysis of one side of the body), expressive language disorder (a communication disorder impacting a person's ability to communicate their thoughts), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's History and Physical, dated 11/1/24, indicated Medical Doctor 1 (MD 1) planned for a wound care consult, currently foam dressing to right dorsal [top of foot] foot ulcer every Monday, Wednesday, Friday. MD 1 noted the wound measurement taken on 10/4/24 was, 1 centimeter [cm-a unit of measure] x 1cm x 0.2cm. […]

• No harm, potential for more than minimal, widespreadF925Jul 28, 2025

  Based on observation and interview, the facility failed to maintain an effective pest control program when flies were observed in common hallways and three resident rooms and four resident rooms had torn window screens.This failure decreased the facility's potential to prevent vector (an insect or rodent that transmits bacteria and viruses) borne illnesses for a census of 54 residents.During a concurrent observation and interview on 7/28/25 at 10:30 a.m., Resident 3 was lying in bed. Upon observation a half full and open urinal and partially eaten personal food items had been placed on Resident 3's bedside table. In addition, a strip of fly paper with 3 dead flies attached and a live fly was seen on Resident 3's curtain Resident 3 stated he had seen flies in his room, all the time. […]