Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Two residents in the facility did not receive adequate pressure ulcer care, leading to deficiencies in treatment and prevention. One resident developed a deep tissue injury on the right heel, and despite recommendations from a wound physician, the facility failed to implement necessary treatments like skin prep every shift and a pressure off-loading boot. Another resident with a long-standing pressure wound on the left heel did not receive the recommended offloading measures. Observations and staff interviews confirmed the lack of appropriate interventions, highlighting a failure in communication and execution of care plans.
A resident with Alzheimer's and major depression did not receive necessary behavioral health services and psychotropic medications as ordered. Recommendations for medications like Remeron, Ativan, and Depakote were not communicated to the physician, and the resident's Trazadone and Risperidone were discontinued without authorization, leading to increased behavioral issues. Staff interviews revealed communication lapses and inadequate follow-up on the resident's care needs.
The facility failed to maintain adequate staffing levels to meet residents' personal care needs, as outlined in their staffing plan. Despite having a detailed staffing plan, the facility did not meet the required hours per patient per day for nursing staff and CNAs on multiple occasions. Corporate Nurse #1 acknowledged the issue, citing new leadership and a lack of awareness as contributing factors.
The facility failed to ensure accurate documentation and maintain complete medical records for several residents. A resident with an AV fistula had blood pressure readings inaccurately documented from the wrong arm. Another resident's MOLST form was unsigned, and their MDS was inaccurately coded. Additionally, a resident's use of multipodus boots was not properly documented, and another resident's blood pressure was taken from an arm with dialysis access, contrary to orders.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident with Alzheimer's and Major Depressive Disorder had a Health Care Proxy that was not invoked, yet consent for Trazadone was signed by the proxy. Another resident with severe cognitive impairments was given Lorazepam and Mirtazapine without documented consent. Staff interviews confirmed that consents should be obtained on admission, annually, and when new medications are started.
A resident with COPD and sleep apnea experienced a malfunctioning CPAP machine, which was not reported to a physician or provider by the facility staff. Despite the resident's complaints and visible error codes on the machine, there was no documentation of notification to healthcare providers. Interviews revealed communication lapses among staff, leading to a delay in ordering a replacement machine.
The facility failed to secure resident PHI on a nursing unit. On two occasions, nurses left medication carts unattended with computer screens open, displaying electronic health records in the hallway. The nurses acknowledged the oversight, and the DON confirmed that screens should be locked when unattended.
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months due to a drainage issue. Residents and a family member expressed frustration over the inconvenience and impact on quality of life. The Maintenance Director admitted to not starting necessary repairs, awaiting authorization, and expressed reluctance to reopen the bathroom without further system flushing.
The facility failed to implement personalized care plans for two residents, leading to deficiencies in care. One resident did not receive physician-ordered multipodus boots, despite being at high risk for pressure ulcers, and there was no documentation of refusal. Another resident with hearing loss and dementia lacked a care plan for hearing deficits, despite documented difficulties. Staff interviews revealed a lack of awareness and documentation, indicating a failure to adhere to facility policies.
A resident with heart failure and muscle weakness did not receive scheduled showers for over five months, despite facility policy requiring weekly showers. The resident, who has intact cognition, reported only having two showers since admission. Staff interviews confirmed the expectation of weekly showers, but there was no documentation of refusal in the resident's medical chart.
The facility failed to change a diabetic resident's wound dressings daily as ordered, resulting in discolored and odorous dressings. Additionally, the facility did not notify a physician of significant weight changes in a resident with congestive heart failure, despite orders to do so. Both deficiencies indicate lapses in following physician orders and monitoring protocols.
The facility failed to address significant weight changes in three residents, including a resident with a 14.63% weight loss, another with an 8.24% weight gain, and a third with a 13.35% weight loss. Nutritional interventions were not implemented for the first resident due to hospice status, educational interventions were not attempted for the second resident despite diabetes, and the third resident was not reweighed after a significant weight loss. The facility's policies on weight monitoring and intervention were not followed.
The facility failed to provide proper respiratory care for two residents. One resident did not have physician's orders for CPAP settings, and their CPAP machine was not functioning, leading to restless nights. Another resident's oxygen administration lacked a specific flow rate in the physician's orders. Staff interviews confirmed these deficiencies.
The facility failed to ensure emergency supplies, including a non-serrated clamp, were available at the bedside for two residents receiving hemodialysis. One resident with end-stage renal disease confirmed the absence of emergency supplies in their room, which was verified by inspection. Another resident, also receiving dialysis through a chest port, was observed without a clamp at the bedside. The DON acknowledged the policy requirement for maintaining a clamp in the rooms of residents receiving dialysis.
A facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, despite having a policy requiring such plans. The resident, with diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, had specific triggers related to discharge discussions that were not addressed in the care plan. Staff interviews confirmed the absence of a trauma care plan, which should have been in place.
A nurse in an LTC facility made five medication errors out of 26 opportunities, resulting in a 19.23% error rate. The errors affected a resident, with medications administered over two hours late and Metformin not given with breakfast as ordered. The nurse acknowledged the timing errors, and the DON confirmed the policy of administering medications within one hour of the scheduled time.
The facility failed to label and store medications according to professional standards, with two medication carts containing opened and undated medications. Additionally, unlicensed personnel were left unsupervised in the medication room, contrary to facility policy. The DON confirmed that nurses are responsible for dating medications and supervising non-nursing staff in the medication room.
The facility failed to follow infection prevention protocols, as a nurse and CNA did not wear precaution gowns during a dressing change for a resident on enhanced barrier precautions (EBP). Additionally, the nurse did not perform hand hygiene between glove changes, citing a lack of hand sanitizer. These actions were contrary to the facility's policies on EBP and hand hygiene.
A facility failed to maintain accurate medical records for a diabetic resident with a history of foot wounds. Despite physician orders to monitor and evaluate the resident's feet, the Treatment Administration Record repeatedly marked foot care as 'Not Applicable' without documenting the resident's refusal of care. Staff interviews confirmed the resident often refused foot care, but these refusals were not recorded, contrary to facility policy.
Failure to Implement Pressure Ulcer Care Recommendations
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in their treatment and prevention of new ulcers. Resident #108, who was at high risk for developing pressure ulcers, developed a deep tissue injury on the right heel while in the facility. Despite recommendations from a consultant wound physician, the facility did not implement the necessary treatments, such as applying skin prep every shift and using a pressure off-loading boot. Observations showed that Resident #108's heels were often directly on the mattress, and the air mattress settings were not adjusted according to the care plan, potentially compromising the effectiveness of pressure relief. Resident #100, who had a pressure wound on the left heel for over 210 days, also did not receive the recommended care. The facility failed to ensure the use of a pressure off-loading boot and did not consistently offload the resident's heels from the mattress. Despite clear orders and recommendations from the wound physician, the necessary interventions were not in place, and staff interviews confirmed the lack of appropriate offloading measures. The facility's policies on consultant services and pressure injury management were not followed, as evidenced by the lack of timely implementation of the wound physician's recommendations. Interviews with staff, including the Director of Nursing, highlighted a failure in communication and execution of care plans, contributing to the worsening of pressure areas for both residents. The deficiencies observed indicate a significant lapse in adhering to professional standards of practice for pressure ulcer care.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with Alzheimer's Disease, major depression, and unspecified dementia with behavioral disturbances. The resident was admitted with prescriptions for Risperidone and Trazadone, but the facility did not implement recommendations from the Psychiatric Nurse Practitioner or ensure that psychotropic medications were administered as ordered. The resident exhibited increased agitation, aggression, and other behavioral issues, which were not adequately addressed by the facility's staff. The facility's policy required that recommendations from health care consultants be communicated to the attending physician for approval and implementation. However, the recommendations to initiate Remeron, Ativan, and Depakote were not relayed to the physician, and the medications were not administered. Additionally, the resident's Trazadone and Risperidone were discontinued without authorization, leading to a period where the resident was without necessary psychotropic medications, exacerbating their behavioral issues. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's behavioral health needs. The Psychiatric Nurse Practitioner and nursing staff were unaware that the recommended medications were not administered, and the Director of Nursing was not informed of the discontinuation of the resident's medications. The facility's failure to adhere to its policies and ensure proper medication management contributed to the resident's ongoing behavioral disturbances and incidents of aggression.
Staffing Deficiency in Nursing Home
Penalty
Summary
The facility failed to maintain sufficient staffing levels to adequately meet the personal care needs of its residents. The staffing plan outlined in the Facility Assessment included a variety of nursing roles such as a Director of Nursing, Assistant Director of Nursing, unit managers, and a weekend supervisor. However, the position for the second shift supervisor was open, indicating a gap in leadership during that shift. The staffing plan also detailed the number of nurses and certified nursing assistants (CNAs) required per shift, with specific ratios for each shift. Despite this plan, the facility's HPPD (hours per patient per day) report revealed that the facility did not meet the appropriate staffing levels for 23 out of 91 days from January through March 2024, and for 26 out of 92 days from May through July 2024. During an interview, Corporate Nurse #1 acknowledged the staffing issues, attributing them to new leadership and a lack of awareness of the problem. The facility's failure to meet the budgeted hours for both nursing staff and CNAs on numerous occasions suggests a systemic issue in maintaining adequate staffing levels. This deficiency in staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfall.
Inaccurate Documentation and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for several residents, leading to multiple deficiencies. For Resident #46, the staff inaccurately documented that blood pressures were taken from the left arm, despite the resident having an AV fistula in that arm, which should not be used for such procedures. This was confirmed by the resident and the Director of Nursing, who emphasized the importance of accurate documentation to prevent potential harm. Resident #80's medical record was incomplete and inaccurately coded. The facility failed to maintain a valid MOLST form, as it lacked the necessary signature from the resident or their responsible party. Additionally, the Health Care Proxy activation form was incomplete, and there was no physician order to invoke the HCP. The MDS was inaccurately coded regarding the resident's advanced directive status, and the medical record lacked physician notes, which are essential for a complete medical record. For Resident #16, the facility did not accurately document the use of multipodus boots, which are crucial for pressure ulcer prevention. Observations showed the resident was not wearing the boots as ordered, yet the nursing progress notes and MAR indicated otherwise. Similarly, for Resident #53, the staff documented blood pressure readings from the left arm, which had a dialysis access, contrary to the physician's orders and care plan. The DON confirmed that such documentation was inaccurate and against the facility's policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for two residents. Resident #80, who was admitted in June 2024 with diagnoses including Alzheimer's disease and Major Depressive Disorder, had a Health Care Proxy (HCP) on file that had not been invoked by a physician. Despite this, a consent for the psychotropic medication Trazadone was signed by the resident's designated HCP. The clinical record did not indicate that Resident #80 consented to the administration of Trazadone or had deferred to the HCP to sign on their behalf. Interviews with facility staff confirmed that the HCP should not be activated until a physician completes the necessary activation form and writes an order, and until then, the resident should sign their own consents. Resident #98, admitted in April 2023 with severe cognitive impairments and diagnoses including metabolic encephalopathy, bipolar disorder, and PTSD, was administered psychotropic medications Lorazepam and Mirtazapine without documented informed consent. The resident's medical record lacked evidence of psychotropic consent for these medications, which were administered according to physician orders. Interviews with nursing staff revealed that psychotropic medication consents are expected to be obtained upon admission, annually, and when new psychotropic medications are initiated, but this protocol was not followed for Resident #98.
Failure to Notify Provider of Malfunctioning CPAP Machine
Penalty
Summary
The facility failed to notify a physician or provider about a malfunctioning Continuous Positive Airway Pressure (CPAP) machine for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine had not been functioning since 8/18/24, causing restless nights and fatigue. Despite the resident's complaints and the visible error code on the machine, the facility did not document any notification to a healthcare provider about the issue. Interviews with facility staff revealed a lack of communication and documentation regarding the malfunctioning CPAP machine. The Assistant Director of Nurses (ADON) acknowledged the need to inform a provider and document the issue, but this was not done. The Nurse Practitioner was unaware of the problem, and the Admissions Director indicated a delay in ordering the replacement machine due to missing information. The Director of Nurses confirmed that the nursing staff should have notified a physician or Nurse Practitioner and documented the situation in the medical record.
Failure to Secure Resident PHI on Nursing Unit
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on one of its nursing units. On two separate occasions, a nurse on the A unit left her medication cart unattended with the computer screen open, displaying the electronic health record in the hallway. This occurred on the morning of August 27, 2024, when the nurse was preparing and administering medications. During an interview, the nurse acknowledged that she should have locked the computer screen to prevent PHI from being visible when she walked away. A similar incident occurred on August 28, 2024, when another nurse on the A unit left her medication cart unattended with the computer screen open, exposing PHI. The Director of Nurses confirmed in an interview that nurses are expected to close or lock computer screens when they leave them unattended to protect resident information.
Facility Fails to Provide Access to Main Floor Bathroom
Penalty
Summary
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months. During a Resident Group Meeting, residents expressed their frustration over the inconvenience caused by the bathroom's unavailability, as they have to return to their units during meals to use the restroom. A family member also highlighted the negative impact on residents' quality of life, as they may miss meals and activities due to the need to go back upstairs. The Maintenance Director revealed that the bathroom was kept out of service due to a drainage issue, not a cracked toilet as residents were told. Despite having vendors clear the blockage in May, the bathroom remained closed to prevent potential re-clogging by certain residents. The Nursing Home Administrator acknowledged a significant plumbing issue that caused flooding but deferred to the Maintenance Director for repair status. The Maintenance Director admitted to not starting the process of obtaining quotes for necessary repairs, awaiting authorization from the Regional Director, and expressed reluctance to reopen the bathroom without further system flushing.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement a resident-centered personalized care plan for two residents, leading to deficiencies in their care. For Resident #16, who was admitted with diagnoses including cerebral infarction and chronic leg syndrome, the facility did not implement the use of multipodus boots as ordered by the physician. Despite the resident being at high risk for pressure ulcers, observations over several days showed that the resident was not wearing the boots, which were instead found on the windowsill. The nursing progress notes did not document any refusal by the resident to wear the boots, and staff interviews revealed a lack of awareness and documentation regarding the resident's use of the boots. For Resident #105, who was admitted with conductive hearing loss and dementia, the facility failed to develop a care plan addressing the resident's hearing deficits. The resident's MDS assessment indicated severe cognitive deficits and an active diagnosis of bilateral conductive hearing loss. During an interview, the resident did not respond to questions, indicating difficulty hearing. A nursing progress note highlighted the resident's difficulty during a therapy session due to hearing issues, yet no care plan was developed to address this need. Staff interviews confirmed the absence of a care plan for the resident's hearing loss, which should have been implemented upon admission. These deficiencies highlight the facility's failure to adhere to its policies regarding the development and implementation of comprehensive care plans tailored to individual resident needs. The lack of proper documentation and communication among staff contributed to the oversight in providing necessary care and services to the residents, as outlined in the facility's policies.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #100, who was admitted in August 2023 with diagnoses including heart failure and muscle weakness. The facility's policy on Activities of Daily Living (ADL) requires that residents receive assistance to maintain or restore maximum functional independence, with a program of assistance developed based on individual evaluations. Despite this policy, Resident #100, who has intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, reported not having taken a shower in over six months. The resident's care plan, last revised in July 2024, indicated a need for substantial/maximal assistance with showering, yet documentation showed no showers were provided in the last five months. Interviews with facility staff, including CNAs and a nurse, confirmed that all residents are scheduled for weekly showers, and any refusals should be documented. However, there was no documentation in Resident #100's medical chart indicating any refusal of showers. The resident expressed a desire to have a full shower occasionally, despite discomfort due to nerve sensitivity. The Director of Nursing also confirmed that scheduled showers should be provided unless refused, yet the lack of documentation suggests a failure in adhering to the facility's policy and ensuring the resident's needs were met.
Failure to Follow Physician Orders for Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to ensure proper wound care for a resident with diabetes, as the daily dressing changes ordered by the physician were not performed. The resident, who was cognitively intact and required supervision for daily tasks, was observed with discolored and odorous dressings on both feet, which had not been changed as per the physician's orders. The Assistant Director of Nursing confirmed that all physician orders should be followed, and daily notes should be written for wound changes, indicating a lapse in adherence to these protocols. Additionally, the facility did not follow a physician's order for monitoring a resident with congestive heart failure. The resident, who had intact cognition and required maximal assistance for showering, had significant weight fluctuations that met the parameters for physician notification. However, there was no documentation indicating that the physician was informed of these changes. The Director of Nursing acknowledged that the physician should have been notified of the weight changes, but there was no evidence that this occurred, highlighting a failure in communication and monitoring processes.
Failure to Address Significant Weight Changes in Residents
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of three residents, leading to significant weight changes that were not properly addressed. Resident #66 experienced a total weight loss of 14.63% over four months, yet no nutritional interventions were implemented despite the facility's policy requiring such actions. The Registered Dietitian (RD) acknowledged the oversight, attributing it to the resident's hospice status, although the Director of Nursing (DON) confirmed that nutritional interventions should still be applied in such cases. Resident #86 experienced an 8.24% weight gain over three months, which was not addressed with appropriate educational interventions. The RD admitted to focusing primarily on weight loss and did not attempt to educate the resident due to their non-verbal and aphasic condition, despite the availability of translator services. The DON expressed concern over the lack of intervention, especially given the resident's diabetes diagnosis, which makes weight gain particularly concerning. Resident #34 was not weighed in July, and a significant weight loss of 13.35% was recorded in August without a reweigh to confirm accuracy. The RD noted the missing weight but did not follow up adequately, and the DON confirmed that reweighs are expected in such cases. The resident's CNA reported that the resident had a good appetite and did not refuse to be weighed, indicating a lapse in the facility's weight monitoring protocol.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident, the facility did not ensure that the physician's orders included settings for a Continuous Passive Airway Pressure (CPAP) machine, nor did they ensure that the CPAP machine was functioning and available for use. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, reported that the CPAP machine had not been functioning since a specific date and that the facility was responsible for obtaining a replacement. Despite being aware of the issue, the facility had not replaced the machine, leading to the resident experiencing restless nights and fatigue. For another resident, the facility failed to obtain a complete physician's order for oxygen administration that included an oxygen flow rate. This resident, who had moderate cognitive impairment and diagnoses including COPD and emphysema, was observed using oxygen via nasal cannula at a specific flow rate. However, the physician's orders did not specify the liter flow for oxygen administration, which was acknowledged by the nursing staff as a deficiency. The facility's policies for CPAP/BiPAP management and oxygen administration were not followed, as evidenced by the lack of specific orders and functioning equipment for the residents. Interviews with nursing staff and the Director of Nurses confirmed the deficiencies in the orders and the failure to replace the malfunctioning CPAP machine, which had been known for over a week.
Failure to Provide Emergency Supplies for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents who required such services. Specifically, the facility did not ensure that emergency supplies, including a non-serrated clamp, were available at the bedside for residents receiving hemodialysis. Resident #46, who has end-stage renal disease and requires dialysis, reported that there were no emergency supplies in their room. This was confirmed during an inspection of the room, where no clamp was found. The Director of Nursing acknowledged that the facility's policy requires a clamp to be maintained in the room of all residents receiving dialysis treatment. Similarly, Resident #51, who also has end-stage renal disease and receives dialysis through a central line in the chest, was observed without any emergency supplies or clamp at the bedside. Despite the care plan indicating the need for dialysis through a chest port, Nurse #7 confirmed that there was no clamp in the room and was unaware of any policy requiring one. The Director of Nursing reiterated the expectation that the dialysis policy, which includes maintaining an emergency clamp, should be followed.
Failure to Develop Trauma Informed Care Plan for Resident
Penalty
Summary
The facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, as required by their policy. The policy mandates that social services screen each resident for a history of trauma upon admission and document a trauma-informed care plan in the resident's medical record. However, for Resident #75, who has diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, no such care plan was documented. The resident had a history of trauma, which was known to the facility staff, and specific triggers related to discharge discussions were identified as exacerbating the resident's behaviors. Despite the resident's known trauma history and the identification of specific triggers, the care plan did not include any resident-specific interventions or triggers. Interviews with the social worker and the Director of Social Service confirmed that a trauma care plan should have been in place. The Director of Social Service acknowledged the absence of the care plan, attributing it to the resident not disclosing the trauma directly to her, despite the resident's previous disclosure of a significant trauma situation during a prior stay at the facility.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 19.23% error rate observed during a survey. Nurse #4 was responsible for five medication errors out of 26 opportunities, impacting one resident. The errors involved administering medications outside the prescribed one-hour window and failing to give Metformin with breakfast as ordered. Specifically, medications including Metformin, Metoprolol, Methocarbamol, Lantus insulin, and Colace were administered over two hours past the scheduled time. Resident #86, who was affected by these errors, had specific physician orders for medication administration times and conditions, such as taking Metformin with breakfast. During interviews, Nurse #4 acknowledged the failure to administer medications within the appropriate time frame and not adhering to the order to give Metformin with breakfast. The Director of Nurses confirmed the policy that medications should be administered within one hour of the scheduled time and that medications ordered with meals should be given accordingly.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to accepted professional standards of practice. Specifically, two of the four medication carts were found to contain medications that were opened and undated, contrary to the manufacturer's guidelines. In the A wing medication cart #1, the surveyor observed an opened and undated Symbicort inhaler, Advair diskus inhaler, Lispro insulin pen, and a bottle of prosource liquid protein, all of which require specific discard timelines after opening. Similarly, in the A wing medication cart #2, an opened and undated Incruse inhaler was found. Interviews with nursing staff, including Nurse #8 and Nurse #2, confirmed that the medications should have been labeled with open dates, and the Director of Nurses reiterated that the responsibility for dating medications lies with the nurse who opens them. Additionally, the facility failed to supervise unlicensed personnel in the medication room, which is against the facility's policy. Nurse #2 allowed a maintenance worker and a substance abuse counselor into the medication room and left them unsupervised. The Director of Nursing confirmed that only nurses are permitted in the medication room, and any other employees must be supervised by a licensed nurse at all times. This lack of supervision and adherence to medication storage protocols represents a significant deviation from the facility's policies and accepted professional standards.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to transmission-based precautions and proper hand hygiene practices, leading to deficiencies in infection prevention and control. Specifically, a nurse and a certified nursing assistant (CNA) did not don precaution gowns while caring for a resident on enhanced barrier precautions (EBP) during a pressure ulcer dressing change. Despite a sign indicating the requirement for gowns and gloves for high-contact activities, both staff members only wore gloves throughout the procedure. Interviews revealed a misunderstanding of the EBP requirements, with the CNA believing gown use was optional and the nurse acknowledging the oversight. Additionally, the nurse failed to perform hand hygiene between glove changes during the dressing change procedure. The nurse removed and donned new gloves multiple times without using hand sanitizer, citing the absence of hand sanitizer as the reason for this lapse. The Director of Nurses confirmed that hand hygiene should be performed each time gloves are removed and before donning new ones, as per the facility's hand hygiene policy.
Inadequate Documentation of Diabetic Foot Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with diabetes, who had physician orders to monitor and evaluate skin integrity on their feet. Despite having a physician's order to observe and care for the resident's feet, the Treatment Administration Record (TAR) for March 2024 repeatedly documented diabetic foot care as 'Not Applicable' (N/A) without supporting documentation of the resident's refusal of care. The facility's policies required documentation of the resident's condition and care provided, as well as documentation of any refusal of treatment, which was not adhered to in this case. The resident, admitted in October 2023, had multiple diagnoses including diabetes, end-stage renal failure, dementia, and a history of foot wounds. Interviews with facility staff, including a Unit Manager and a nurse familiar with the resident, confirmed that the resident often refused foot care. However, the staff failed to document these refusals in the medical record, as required by facility policy. The Director of Nurses acknowledged that the documentation should have reflected the resident's behavior and refusals, indicating that the use of 'N/A' was inappropriate for documenting the resident's foot care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| D'youville Senior Care | 0.1 mi | — | 6 | 0 |
| D'youville Care For Advanced Therapy | 0.2 mi | — | 0 | 0 |
| Fairhaven Healthcare Center | 1 mi | — | 36 | 0 |
| Regalcare At Lowell | 1.8 mi | — | 21 | 1 |
| Palm Springs Post Acute | 1.9 mi | — | 12 | 0 |
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