North Healthcare And Rehabilitation Center

Based on record review and interviews, the facility failed to have eight consecutive Registered Nurse (RN) hours seven days a week for seventeen of ninety-one days in the third quarter of Fiscal Year (FY) 2025.Findings included: Review of Payroll Based Journal (PBJ) Data (FY) Quarter 3 2025 (April 1-June 30) revealed no RN Hours were Triggered on 10/05/2024; 10/12/2024; 10/13/2024; 4/5/2025; 4/6/2025; 4/12/2025; 4/13/2025; 4/19/2025; 4/20/2025; 4/26/2025; 4/27/2025; 5/11/2025; 5/25/2025; 5/26/2025; 5/31/2025; 6/1/2025 and 6/21/2025.During an interview on 9/4/25 at 09:50 a.m., with Staff H, Staffing Coordinator, employed for one year, stated, It is my responsible to staff the building and when I staff the building, I make sure that I have enough Licensed Practical Nurses (LPN) and RNs to meet the needs of the residents. For instance, if I have 38 residents, .when it comes to nurses, I try to always have two to three RN's and LPN's, which we're required to have an RN on staff eight hours a day. If I do not have an RN working on the floor for med [medication] pass, I use the Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility did not ensure chemicals were secured and the smoking policy was followed for two residents (#32 and #50) out of seven residents that smoke. Finding included: An observation was conducted on 9/3/25 at 9:29 a.m. of Residents #32 and #50. Both residents were on the smoking patio with no staff present or in sight of the residents and no smoking aprons on or available. It was also observed that a shed on the patio was unlocked. The shed had a CAUTION HAZARDOUS CHEMICALS. AUTHORIZED PERSONNEL ONLY sign on the door and inside the shed were multiple bottles of chemicals observed.An observation was conducted on 9/3/25 at 1:18 p.m. of Resident #32 on the smoking patio with no staff present or within sight and no smoking apron on or available. Resident #32 was sitting in his/her wheelchair slumped over asleep. The resident woke up when his/her name was called. Upon waking up it was observed Resident #32 had a lit cigarette in their right hand. The shed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility did not ensure infection control practices were followed related to: 1) food handling; 2) a non-cleanable surface and storage of a respiratory mask in two out of two resident rooms. Findings included: 1. On 9/3/25 at 10:31 a.m., an observation of Resident #2 revealed he was sitting in the wheelchair using a yellow gait belt to maneuver between the bed and the window. He lifted up the mattress and revealed a flattened cardboard box on top of the bed frame. He said facility staff put the cardboard box there because the bar in the middle of the bed was hurting his back. Further observations of the top of the cardboard box revealed particles of food and other small debris. A review of Resident #2’s admission record revealed an initial admission date of 11/7/22 and a re-admission date of 3/29/23. Further review of the admission record revealed diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility did not ensure one resident (#7) was assisted out of bed daily and splints were placed for one resident (#27) out of thirteen sampled residents.Findings included: An observation was conducted on 9/3/25 at 9:25 a.m. of Resident #7. The resident was observed to be lying in bed flat on his/her back with a neck support pillow. The resident remained in this position throughout the day. An observation was conducted on 9/4/25 at 10:09 a.m. and 12:00 p.m. of Resident #7 lying flat in the bed with a neck support pillow in place. Review of Resident #7’s “admission Record” showed Resident #7 was admitted on [DATE] with diagnoses of unspecified fall, dementia, cerebral infarction, muscle weakness, difficulty in walking, and need for assistance with personal care. Review of Resident #7’s quarterly Minimum Data Set (MDS), dated , 6/8/25, Section C, cognitive patterns, showed a score of 99, indicating the resident was unable to complete the interview. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to honor the right of a resident or his/her legal representative to receive medical records timely, within two working days, for three (#1, #7, and #8) of three sampled residents reviewed for medical record request. Findings included: On 02/12/2025 at 9:55 a.m., a phone interview was conducted with Resident #1's representative. When asked if she was involved in the admission process for (Resident #1), she stated, yes. When asked if she signed a contract during the admission process, she stated, No contract, I just signed a consent to treat. When asked if she had requested medical records, she stated, I asked for a copy of the medical cost responsibilities. An interview conducted on 02/12/2025 at 2:09 p.m. with the Nursing Home Administrator, when asked if the resident/representative had requested medical records for Resident #1, she stated no, the only thing she asked for was a copy of the insurance conversion letter, which I supplied her with. No documentation was provided as to the date of the request or the fulfillment of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility did not label, date and/or cover food items stored in the refrigerator or freezer. Findings included: An observation, on 09/05/23 at 9:20 a.m., showed a reach-in refrigerator in the kitchen area that contained: - Three (3) sandwiches not labeled or dated. - A big bag of lettuce not labeled or dated. - 1 package of lunch meat smoked ham not dated. - An open package of orange square cheese slices with package ripped and left uncovered. (photographic evidence obtained) During an interview on 09/05/23 at 9:20 a.m., Staff A Dietary Manager (DM) stated food items stored in the refrigerator should be labeled and dated. Staff A stated the cheese should have been covered and stored appropriately. An observation, on 09/05/23 at 9:30 a.m., showed a reach-in freezer in the kitchen that contained: - Two whole frozen chicken breasts not labeled or dated. - Six frozen bags of broccoli (2 pounds and 8 ounces) each not labeled or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean homelike environment on two out of two units and failed to ensure medical equipment was in good repair for two (Residents #11 and #26) of 21 sampled residents related to two out of six shower chairs and one out of two [brand name] positioning chairs not being in good condition. Findings included: An observation was made on 9/5/23 at 7:20 a.m. on the resident smoking patio of flower beds being overgrown with grass and weeds and trash around the area, including a medical glove in the middle of the patio on the ground. On 9/6/23 at 1:35 p.m. the patio remained in the same condition. An observation was made on 9/5/23 at 12:35 p.m. of the linen closet on a box on the floor that appeared to have a water stain on it. The box had yellow gowns spilling out on the floor with black marks on the sleeves. The linen closest also contained three pillows in a plastic bag stored on the floor. An observation was made on 9/5/23 at 12:37 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure advanced care planning with a legal appointed designated health care proxy or power of attorney (POA) was completed for one (Resident #9) out of the sampled twenty-one residents. Findings included: On 09/05/23 at 12:12 p.m. Resident #9 was observed lying in bed. Resident #9 was not able to respond to questions in an attempted interview. A review of the admission Record for Resident #9 did not reflect the resident had a health care proxy or a POA. Resident #9 was admitted on [DATE] with diagnoses to include anxiety disorder and cognitive communication deficit. A review of the admission Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score was not obtained and showed the resident was rarely/never understood. A review of Resident #9's annual MDS, dated [DATE], Section C - Cognitive Patterns revealed a BIMS score was not obtained and showed the resident was rarely/…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure the physician was informed about refusal of medications and dialysis services for one (Resident #194) of six sampled residents. Findings Includes: On 9/5/2023 at 11:45 a.m., Resident #194 was observed in her room sitting up in her wheelchair with her call light within reach. The resident was well groomed. The room was clean and well lit. A review of the admission Record showed Resident # 194 was admitted to the facility on [DATE] with diagnoses to include but not limited to Epilepsy, Cognitive Communication, Conversion Disorder with Seizures or Convulsions, End Stage Renal Disease, and Dependence on Renal Dialysis. A review of admission Minimum Data Set, dated [DATE], Section C, Cognitive Patterns, C0600, Titled, Should the Staff Assessment for Mental Status be conducted, Code entered showed 0, indicating No. The resident was able to complete a Brief Interview for Mental Status. A review of the Order Summary Report dated 9/7/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner during two of two visits conducted on 10/04/21 at 9:37 a.m. and on 10/05/21 at 11:20 a.m., related to proper food storage, equipment and surface cleanliness, and storage of personal items in food prep and food storage areas. Findings included: An initial tour of the kitchen was conducted on 10/04/21 at 09:37 a.m. facilitated by the Certified Dietary Manager (CDM). An observation was made of Staff B, Dietary Aide standing in front of the food prep counter. Staff B was noted without a face mask. Staff B proceeded to grab her mask that was resting on the food prepping counter and held it on her right hand. A blue drinking cup with a straw and a cell phone were resting on the food prep counter. Next to the cell phone was a package of an opened snack and a small bag that was not opened. Also, on the counter were food service items including condiments in sachets and napkins. An interview was conducted on 10/04/21 at 9:38 a.m. with Staff B. Staff B stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure meals were served in a dignified manner related to staff standing when assisting a resident with meals during two of two observations for Resident #33. Findings included: During a facility tour on 10/04/21 at 12:40 PM, an observation was made of Staff B, CNA (Certified Nursing Assistant) assisting Resident #33 with the lunch meal while standing. Staff B was observed standing to the left of Resident #33's bed, spooning food into her mouth. An interview was conducted with Resident #33 on 10/04/21 at 12:55 PM. Resident #33 stated that staff were always standing by her bed during mealtime. Resident #33 said, Every once in while a CNA will bring a chair, but not [Staff B]. On 10/05/21 at 12:51 PM, an observation was made of Staff C, CNA assisting Resident #33 with her meal while standing. A follow -up interview was conducted with Staff C on 10/05/21 at 1:03 PM. Staff C said, I stand when assisting residents. I don't sit. No one ever…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not honor a resident's preference to receive therapy services for one (Resident #33) of twenty residents. Findings included: During a facility tour on 10/04/21 at 10: 45 AM, Resident #33 stated that she had been at this facility since June 2021 and had not received any therapy. Resident # 33 said, I have been asking for over 2 months. Resident #33 said, Please look into it. I want to be able to take care of myself. I need therapy. I don't want to be a dependent for the rest of my life. Resident #33 stated that she had spoken to the Social Services Director (SSD) and the Director of Rehabilitation (DOR) about receiving restorative services. A review of Resident #33's electronic medical record (EMR) showed a resident information sheet revealing that Resident #33 was [AGE] years old and was admitted to the facility on [DATE]. Resident #33 was her own responsible party and was admitted with diagnoses to include, but not limited to insomnia, major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure that one (Resident #21) of four residents reviewed was notified prior to a room change. Resident #21 was admitted to the facility on [DATE] with a primary diagnosis of HB-SS Disease (Sickle Cell Anemia) with cerebral vascular involvement. Resident # 21's most recent Minimum Data Set (MDS), dated [DATE],Section C: Cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 10/04/21 at 2:45 p.m. an interview was conducted with Resident #21. He stated that he was moved from his prior room a few days ago. Resident #21 stated that he was not notified of the room change ahead of time. The staff did not give him a chance to get out of bed, while still in bed, he was rolled across the hall to the new room. On 10/06/21 11:15 a.m. an interview was conducted with the Social Services Director. She stated that she did not initiate room changes, the Business Office was responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.