Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northgate Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of sexually inappropriate behavior was left unsupervised in a common area and engaged in sexual abuse of another resident, despite known risks and recent medication changes. Staff failed to provide required supervision and did not complete behavior monitoring as directed. In separate incidents, two residents were subjected to physical abuse by other residents with behavioral histories, and care plans lacked clear supervision directives. Facility policies for abuse prevention and individualized care planning were not followed, leading to multiple substantiated abuse events.
A resident with severe cognitive impairment and a history of behavioral disturbances underwent a GDR of a psychotropic medication without adequate or consistent monitoring for behaviors. Staff failed to follow documentation protocols, and the care plan lacked specific monitoring parameters. Incomplete and inaccurate behavior documentation occurred, and the resident subsequently sexually abused another resident, resulting in Immediate Jeopardy and substandard quality of care.
The facility failed to manage and document behavioral health needs for residents with a history of aggressive and sexually inappropriate behaviors, resulting in an incident where a resident was found unsupervised and engaged in inappropriate sexual contact with another resident. Staff did not consistently document or monitor target behaviors as required, and care plans lacked clear directives for supervision, leading to further incidents of aggression between residents.
The facility employed a Dietary Manager who had not yet completed the required coursework or obtained Certified Dietary Manager (CDM) status, despite serving meals to all residents. The Dietary Manager was still in the process of finishing her training and certification at the time of the survey, which did not meet the facility's job requirements for the position.
Surveyors observed multiple instances of disrepair and uncleanliness in resident rooms and common areas, including unpainted walls, broken blinds, damaged windowsills, chipped furniture, and broken ceiling tiles. Several residents confirmed these issues had persisted for extended periods. The Maintenance Director was unaware of most problems until shown by surveyors, indicating a breakdown in the facility's process for reporting and addressing environmental concerns.
Surveyors found that several hallway handrails were missing end caps, broken, or entirely absent in multiple areas, including near the nurses' stations and between office doors. The MTD and DON confirmed the importance of handrails for resident safety and acknowledged the deficiencies, with some issues persisting for several weeks.
A resident's sponsor was not notified of a room change as required by facility policy. Interviews with the SSD and DON confirmed that Social Services was responsible for this notification, but the sponsor stated she was not informed of the move.
A resident with chronic kidney disease and a physician order for regular dialysis was not accurately coded as receiving dialysis on their quarterly MDS assessment. The Regional MDS Coordinator confirmed the resident was receiving dialysis and that the omission was an oversight during assessment completion.
A resident with a history of benign prostatic hyperplasia and cystitis experienced a delay in laboratory testing after a physician ordered a urinalysis and culture and sensitivity due to increased confusion. Although a nurse documented collecting the specimen, the laboratory never received it, and the test remained pending. Ten days later, another urinalysis was performed, but it was contaminated and no further workup was completed.
A resident with multiple medical conditions was left in a bed with a non-functioning head of bed (HOB) for at least two days due to delayed communication between staff and maintenance. The bed's malfunction prevented proper positioning for care and feeding, and key staff, including the DON and MTD, were not promptly informed of the issue.
The facility did not include the total actual hours worked by RNs, LPNs, MACs, and CNAs on daily nurse staffing posting forms for several days, as required by policy. The posted forms only listed the number of staff scheduled, without reflecting actual hours worked or staff absences, a deficiency confirmed by the DON and observed on multiple occasions.
The facility failed to comply with food safety and hygiene standards, as the Dietary Manager did not wear a beard guard while handling food, and residents were served on paper plates due to a temporary shortage of dinnerware. Additionally, the kitchen stove hood and vents were dirty with grease and dust, posing a risk to food safety.
A resident with COPD did not have their nebulizer equipment maintained according to facility policy, which required storing the mask in a Ziploc bag and changing the tubing weekly. Over four days, the mask was observed uncovered, and the tubing had not been changed since December. Staff confirmed these practices could lead to infection risks.
The facility failed to maintain an effective pest control program, resulting in rodent droppings and roaches in various areas, including the kitchen and resident bathrooms. Residents reported sightings of mice, rats, and roaches over the past six months. The facility's policies on pest control and maintaining a safe environment were not effectively implemented, affecting the quality of life for residents.
The facility failed to provide a safe and homelike environment, as evidenced by a stained privacy curtain, a detaching smoke detector, a hole in the hallway wall, and missing floor tiles. These issues were observed over several days, affecting multiple residents and common areas, and were acknowledged by the facility's staff as deficiencies.
A CNA was observed standing while feeding a resident with severe cognitive impairment and upper extremity impairment, contrary to the facility's policy of maintaining resident dignity. The facility's policy requires staff to be seated at the resident's level during feeding to prevent the resident from feeling rushed.
A resident with a diagnosis of Pulmonary Embolism was receiving the anticoagulant Eliquis, but this was not accurately coded in their Quarterly MDS assessment. The MDS Coordinator confirmed the oversight, which affected the accuracy of the resident's medication records during the assessment period.
A resident at risk for pressure ulcers developed a Stage II ulcer on the back of their right leg, which was not identified during routine skin inspections by CNAs. The ulcer was discovered during a body audit by the Treatment Nurse and an LPN, despite prior assessments not documenting any concerns. The RN supervisor and DON confirmed that CNAs should have been inspecting and documenting skin conditions during care.
A resident experienced a fall in their room due to water on the floor from a leaking AC unit. The incident was documented as an un-witnessed fall, with the resident reporting slipping on the water. Nursing staff confirmed the presence of water and noted that a sheet had been placed to catch the leak, but it was insufficient. The fall was deemed avoidable by the RN who prepared the incident report.
A CNA failed to perform hand hygiene after removing gloves following a feeding task with a resident requiring substantial assistance. This action was observed and confirmed through interviews with the CNA, DON, and RDCO, highlighting a breach in the facility's hand hygiene policy aimed at preventing cross-contamination and infection.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse perpetrated by other residents. One resident with a history of sexually inappropriate behavior, including vulgar comments and obscene language, was found unsupervised in the activity room with another resident, with his hand on the other resident's breast. The resident who committed the act had a documented history of sexual remarks and behaviors, as well as diagnoses including Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. Despite this history and a recent reduction in antipsychotic medication, the facility did not implement or document enhanced supervision or monitoring, and staff failed to complete required behavior monitoring documentation. The care plan for this resident did not provide clear direction regarding supervision requirements, and staff interviews confirmed that residents were left unsupervised in the activity room, contrary to facility policy. Additionally, the facility failed to protect two other residents from physical abuse. In one incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident in the face following a dispute over a bedside table. The care plan for the aggressive resident did not specify the level of supervision required to ensure the safety of others. Staff interviews and facility records confirmed that the incident resulted in physical injury and was substantiated as physical abuse. In another incident, a resident with a history of behavioral issues hit another resident on the arm, but details of this event were not fully elaborated in the provided excerpt. The facility's policies required ongoing oversight, supervision, and individualized care planning for residents with behaviors that could lead to conflict or abuse. However, the facility did not ensure that these policies were implemented as written. Staff interviews revealed a lack of awareness regarding supervision requirements, and documentation showed that behavior monitoring was incomplete or missing. The failure to provide adequate supervision and to follow established care planning and monitoring protocols directly contributed to the incidents of abuse.
Failure to Monitor Behaviors During Psychotropic Medication Dose Reduction Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure adequate and consistent monitoring for behaviors during a Gradual Dose Reduction (GDR) of a psychotropic medication for a resident with a history of behavioral disturbances. The resident, who had diagnoses including paranoid schizophrenia, vascular dementia, bipolar II disorder, and borderline personality disorder, underwent a dose reduction of Seroquel. Despite this change, there was no documented system in place to specify the timeframe or provide clear instructions to staff on how to monitor for behaviors during the GDR process. Documentation by Certified Nursing Assistants (CNAs) and nurses in the Electronic Medication Administration Record (EMAR) was incomplete and did not accurately reflect whether the resident exhibited behaviors or escalation of behaviors during this period. The care plan for the resident did not include parameters for monitoring the resident's condition following the medication adjustment. CNA mood and behavior documentation was frequently missing or incomplete, with many shifts left blank and unclear use of documentation codes. Nursing staff also failed to follow the specified instructions for behavior monitoring in the EMAR, often using check marks instead of the required 'Y' or 'N' responses, and there were no behavior monitoring notes documented in the progress or nursing notes during the critical period after the dose reduction. Fifteen days after the dose reduction, the resident with a known history of sexually inappropriate behaviors sexually abused another resident. The lack of proper monitoring and documentation during the GDR process was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. This resulted in the citation of Immediate Jeopardy and substandard quality of care related to freedom from abuse, neglect, and exploitation.
Failure to Manage and Document Behavioral Health Needs Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents with behavioral health needs received appropriate care and supervision, resulting in unmanaged behaviors that compromised the safety and privacy of other residents. One resident with diagnoses including Schizophrenia, Bipolar Disorder, and a history of sexually inappropriate behavior was found unsupervised in the activity room with another resident, during which an incident of inappropriate sexual contact occurred. Staff did not consistently document the presence or absence of target behaviors as outlined in the care plan, and behavior monitoring was incomplete or inaccurately recorded. Additionally, the facility did not establish or communicate the required level of supervision when a Gradual Dose Reduction (GDR) of psychotropic medication was attempted for this resident. Interviews with staff revealed inconsistent reporting and documentation of the resident's behaviors, including sexually inappropriate comments and verbal aggression. Certified Nursing Assistants (CNAs) and other staff members reported observing behaviors such as cursing, refusal of care, and inappropriate remarks, but these were not always documented or communicated according to facility policy. The care plan for the resident included interventions for monitoring and managing behaviors, but these interventions were not effectively implemented or tracked, leading to a failure in managing the resident's risk to others. A second resident with a history of psychotic and mood disturbances exhibited combative behaviors, including hitting another resident. The care plan for this resident did not provide clear direction regarding the level of supervision required to ensure safety. Staff interviews indicated that while interventions such as removing the resident from situations and de-escalation were used, there was a lack of proactive measures and documentation to prevent incidents. These deficiencies affected multiple residents and were substantiated through record reviews, staff interviews, and direct observation.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified Dietary Manager to oversee the food and nutrition service, which had the potential to affect all 60 residents receiving meals from the kitchen. The Dietary Manager was hired with the understanding that she would complete the required dietary manager course and obtain certification, but at the time of hire and during the survey, she had not yet completed the necessary coursework or obtained Certified Dietary Manager (CDM) status. The Dietary Manager had completed some coursework in Food Safety and Management and was in the process of finishing the final module required to be eligible for the CDM exam. Despite having 25 years of LTC foodservice experience and previous experience as a dietary manager, the Dietary Manager did not meet the facility's stated job requirements for education and certification at the time of employment. The Registered Dietitian confirmed that the Dietary Manager was hired before completing the required training and certification, and that she was still in the process of finalizing her coursework and applying for the CDM exam during the survey period. The deficiency was identified through interviews, review of the employee file, and direct observation.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required by its own policy and regulatory standards. Multiple observations by surveyors revealed numerous areas in both resident rooms and common areas that were in disrepair or unclean. Specific deficiencies included unpainted and plastered walls, chipped paint, missing or broken window blinds, damaged windowsills, chipped furniture, broken and stained ceiling tiles, detaching trim, holes in walls, and missing floor tiles. These issues were present in the rooms of several residents and throughout both units of the facility. Interviews with residents confirmed that some of these environmental deficiencies had been present for extended periods, with one resident stating that a hole in the wall had existed since their admission approximately three months prior. The Maintenance Director (MTD) acknowledged the need for repairs during walkthroughs with the surveyor and indicated that many of the issues had not been previously reported to him. The MTD stated that staff were expected to enter repair needs into the facility's work order system (TELS), but he was unaware of most of the deficiencies until they were pointed out by the surveyor. The facility's policy on maintaining a safe and homelike environment requires prompt reporting and repair of furniture and environmental issues. However, the lack of timely communication and follow-up resulted in prolonged periods where residents lived in rooms and used common areas that did not meet the standards for safety, cleanliness, and comfort. The MTD admitted that the current state of the environment would not be considered homelike.
Failure to Maintain and Secure Hallway Handrails
Penalty
Summary
Surveyors observed multiple deficiencies related to hallway handrails throughout the facility. Several handrails were missing plastic end cap pieces, including those in front of the nurses' station on Unit One, near the respiratory supply closet, and near the social services office. Additional observations revealed a broken handrail outside a resident room and missing end caps outside other resident rooms. The Maintenance Director confirmed awareness of these issues, noting that some handrails had been missing or broken for at least three weeks to a month. Further inspection identified missing sections of handrails between specific office doors and next to the nurses' station on Unit Two. The Maintenance Director provided measurements for the missing handrail sections and acknowledged the absence of handrails in these areas. Both the Maintenance Director and the Director of Nursing stated that handrails are important for resident safety, particularly for those who require assistance with ambulation, as they provide support and help prevent falls. The observations and staff interviews confirmed that the facility failed to ensure that handrails were properly installed and maintained in all required hallway areas.
Failure to Notify Resident's Sponsor of Room Change
Penalty
Summary
The facility failed to notify the sponsor or representative of a resident when the resident experienced a room change on 10/18/2024. According to the facility's policy titled 'Notification of Changes,' the facility is required to contact the resident's physician and notify the resident's representative when such changes occur. Interviews with the Social Service Designee (SSD) and the Director of Nursing (DON) confirmed that the responsibility for notifying family members of room changes lies with Social Services, and that notification should occur before the move. The SSD admitted to not notifying the resident's sponsor, and the sponsor confirmed that she was not informed of the room change. This deficiency was identified during the investigation of a specific complaint and affected one of the sampled residents.
Failure to Accurately Code Dialysis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the receipt of dialysis treatment. The resident, who had diagnoses including dependence on renal dialysis and chronic kidney disease, was readmitted to the facility and had physician orders for renal dialysis three times per week. Despite this, the quarterly MDS assessment with an Assessment Reference Date (ARD) of 01/28/2025 was not coded to indicate that the resident received dialysis. During an interview, the Regional MDS Coordinator confirmed that the resident was receiving dialysis at the time and acknowledged that the omission was an oversight during the completion of the assessment. The failure to accurately document the dialysis treatment on the MDS assessment was identified through observations, interviews, and record review.
Failure to Provide Timely Laboratory Services for Urine Testing
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who had a physician's order for a urinalysis (UA) and culture and sensitivity (C&S) on 07/19/2024. The resident, who had a history of benign prostatic hyperplasia and cystitis, was noted to be more confused on the day the order was placed, prompting the nurse to obtain a urine specimen as ordered. However, the laboratory never received the specimen, and the collection remained pending in their system. Ten days later, another UA was performed, but the results indicated probable urogenital contamination and no further workup was done. This delay and failure to process the initial laboratory order resulted in the resident not receiving timely diagnostic testing as required.
Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in a safe and functional condition at all times. The resident, who had diagnoses including dementia, anxiety, intellectual disabilities, and gastrostomy status, was observed on multiple occasions with the head of bed (HOB) in a flat position due to a malfunctioning bed. Certified Nursing Assistant (CNA) #23 reported that the bed had been broken since the previous day, and the Maintenance Director (MTD) was not informed until a day later. The resident remained in the non-functioning bed for at least two days, during which time the HOB could not be elevated for care or feeding. Interviews with staff revealed a lack of timely communication regarding the bed's malfunction. CNA #23 was unsure when the issue was reported to maintenance, and the MTD stated he was not informed until the day after the problem was first noticed. The Director of Nursing (DON) also confirmed she had not been notified of the issue. Staff acknowledged the importance of a functioning bed, particularly for residents who require the HOB to be elevated during feeding to prevent choking or aspiration, and for general safety and care needs.
Failure to Post Actual Nursing Staff Hours on Daily Staffing Forms
Penalty
Summary
The facility failed to ensure that the total hours actually worked by nursing staff were included on the daily nurse staffing posting forms for five specific days during the survey period. Observations on multiple days revealed that the posted forms listed the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), Medication Assistant Certified (MAC), and Certified Nursing Assistants (CNA) scheduled to work each shift, but did not include a section for the total hours actually worked. This omission was consistent across all observed forms for the affected days, and the forms did not reflect staff absences or actual hours worked as required by the facility's own policy. An interview with the Director of Nursing (DON) confirmed that the posted forms were missing the required information regarding actual hours worked for RNs, LPNs, and CNAs. The DON acknowledged that the facility's policy mandates the inclusion of this information and that it is important for knowing how many staff were present during each shift. The deficient practice was observed on five out of eleven days during the survey and had the potential to affect all 61 residents residing in the facility.
Non-Compliance with Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to adhere to its policy on personal hygiene and food safety standards, as evidenced by the Dietary Manager (DM) not wearing a beard guard while handling food in the kitchen on multiple occasions. Observations on 01/06/2025 and 01/08/2025 revealed the DM without a beard guard, even while placing macaroni salad into bowls. The DM acknowledged the importance of wearing a beard guard to prevent hair contamination in food but admitted to not wearing one on several days. This non-compliance with the facility's dress code policy posed a risk of food contamination for all 52 residents receiving meals from the kitchen. Additionally, the facility did not consistently serve meals on proper dinnerware, as observed on 01/06/2025, when four out of nine residents in the dining room were served on paper plates. A resident confirmed the frequent use of paper plates, expressing a preference for nicer plates. A Dietary Aide explained that paper plates were used due to a temporary shortage of dinnerware, although the DM later stated there was no shortage and that residents should not be served on paper plates unless they were in isolation or sick. Furthermore, the kitchen stove hood and vents were found to be dirty with grease and dust, which the DM acknowledged had not been cleaned, potentially affecting food safety and proper venting.
Failure to Maintain Nebulizer Equipment as per Policy
Penalty
Summary
The facility failed to maintain the nebulizer equipment for a resident, identified as RI #8, in accordance with their policy titled Nebulizer Therapy. The policy required that nebulizer masks be stored in a Ziploc bag to prevent contamination, and that the tubing be changed weekly. However, over the course of four days, from January 6 to January 9, 2025, the nebulizer mask was repeatedly observed not being stored in a Ziploc bag, and the tubing had not been changed since December 22, 2024. This oversight was confirmed through observations and interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Infection Preventionist (IP), both of whom acknowledged the potential for infection due to these lapses. RI #8, who was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was prescribed daily nebulizer treatments with Ipratropium-Albuterol Solution. Despite the clear guidelines outlined in the facility's policy, the nebulizer mask was left uncovered, and the tubing was not replaced as scheduled. The LPN confirmed that the tubing should have been changed on Sunday evenings, and the IP highlighted the risk of bacterial growth when equipment is not stored or maintained properly. These failures in following the established protocol for respiratory care equipment maintenance directly contributed to the deficiency identified during the survey.
Pest Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodent droppings and roaches in various areas. Observations by surveyors revealed rodent droppings in the Dietary Manager's office, the dry storage room in the kitchen, and the nurses' medication room. The Dietary Manager confirmed the presence of rat droppings, which posed a contamination risk. Additionally, adhesive strips with dead roaches were found in a resident's bathroom and the kitchen, indicating a significant pest issue. Residents reported sightings of mice, rats, and roaches in their rooms, bathrooms, and hallways over the past six months. During a Resident Council Group Meeting, multiple residents confirmed these sightings, with one resident specifically mentioning seeing a large roach the previous day. The facility's failure to address these pest issues led to numerous complaints from residents, highlighting the ongoing problem. The facility's policies on pest control and maintaining a safe and homelike environment were not effectively implemented. The Maintenance Director acknowledged a gap beneath an exit door that could allow rodents to enter the building. Despite the facility's policies, the presence of pests and the residents' complaints indicate a failure to provide a clean and comfortable environment, affecting the quality of life for the residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations made by surveyors. In one instance, a privacy curtain in a resident's room was found to be stained with a brown substance, which was later identified by the Housekeeping Supervisor as resembling a bowel movement. This stain remained on the curtain over multiple days, indicating a lack of timely cleaning and maintenance. Additionally, a smoke detector in another resident's room was observed to be detaching from the ceiling, posing a potential safety hazard as noted by the Maintenance Director. Further deficiencies were observed in the common areas of the facility. A hole the size of a baseball was found in the hallway wall adjacent to a resident's room, which the Maintenance Director acknowledged should not be present and detracted from the homelike appearance of the environment. Moreover, two tiles were missing from the floor outside another resident's room, creating a potential tripping hazard. These issues were identified during the investigation of specific complaint/report numbers, affecting three residents and one medication room within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) adhered to the policy of promoting and maintaining resident dignity during meal assistance. On July 30, 2024, CNA #7 was observed standing while feeding a resident, identified as RI #6, during the lunch meal. This action was contrary to the facility's policy, which emphasizes treating residents with respect and dignity, including being seated at the resident's level during feeding to avoid making the resident feel rushed. RI #6, who was admitted with diagnoses including Cognitive Communication Deficit, Dysphagia, and a need for substantial assistance with eating, was affected by this practice. The resident's Quarterly Minimum Data Set (MDS) assessment indicated severely impaired cognition and upper extremity impairment, necessitating maximal assistance with eating. Interviews with CNA #7, the Director of Nursing, and the Regional Director of Clinical Operations confirmed that standing while feeding a resident is a dignity issue and staff should be seated at the resident's eye level.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as RI #12, in their Quarterly Minimum Data Set (MDS) assessment. The deficiency was identified during a review of the resident's records and an interview with the MDS Coordinator. RI #12, who was admitted to the facility with a diagnosis of Pulmonary Embolism without Acute Cor Pulmonale, had been receiving an anticoagulant medication, Eliquis, as per physician's orders since March 2024. However, the MDS assessment with an Assessment Reference Date of July 2, 2024, did not reflect that the resident received this medication during the assessment period. The MDS Coordinator acknowledged that the resident was receiving Eliquis during the seven-day look-back period and that it should have been coded in the MDS assessment. The oversight was attributed to a failure in accurately coding the medication, which is crucial for ensuring that all relevant parties are aware of the medications a resident is receiving. This error affected one of the 26 sampled residents whose MDS assessments were reviewed, highlighting a lapse in the facility's assessment process.
Failure to Identify Stage II Pressure Ulcer
Penalty
Summary
The facility failed to identify a Stage II pressure injury on the back of a resident's right leg during a body audit conducted by the Treatment Nurse and a surveyor. The resident, who was assessed as being at risk for developing pressure ulcers, had a Quarterly Minimum Data Set assessment indicating this risk. However, a Shower Audit/Skin Assessment form dated prior to the discovery did not document any injury or area of concern on the resident's leg. The Certified Nursing Assistant (CNA) assigned to the resident did not recall inspecting the back of the resident's right leg during care, which contributed to the oversight. The deficiency was further highlighted when the Treatment Nurse and another LPN identified the pressure ulcer during a body audit, despite not being informed of the open area beforehand. The RN supervisor and the Director of Nursing both acknowledged that CNAs should have been inspecting the resident's skin during care and documenting any findings on the shower sheets. The failure to identify the pressure ulcer in a timely manner was a result of inadequate skin inspections by the CNAs, as confirmed by interviews with facility staff.
Resident Fall Due to Leaking AC Unit
Penalty
Summary
The facility failed to ensure a safe environment for Resident Identifier (RI) #7, resulting in a fall due to water on the floor from a leaking air conditioner (AC) unit in the resident's room. The incident was documented in an incident report titled 'Un-witnessed Fall,' where the resident was found on the floor beside the bed. The resident reported slipping on water from the leaking AC unit, which was confirmed by the nursing staff present at the scene. The resident experienced soreness and redness but no broken skin or head injury. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), corroborated the presence of water on the floor due to the leaking AC unit. The CNA noted that a sheet had been placed on the floor to catch the leaking water, but it was insufficient to prevent the fall. The RN, who prepared the incident report, stated that the fall was avoidable and attributed it to the water on the floor. This deficiency was identified during the investigation of a complaint, affecting one of the five residents sampled for falls.
Failure to Perform Hand Hygiene After Glove Removal
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a Certified Nursing Assistant (CNA) after feeding a resident. The CNA, identified as CNA #7, was observed on 07/30/2024 feeding a resident diagnosed with Dysphagia and requiring substantial assistance with eating. After completing the feeding task, CNA #7 removed her gloves and exited the resident's room without performing hand hygiene, which is a violation of the facility's hand hygiene policy. Interviews conducted with CNA #7, the Director of Nursing (DON), and the Regional Director of Clinical Operations (RDCO)/Infection Control Nurse confirmed the deficiency. CNA #7 acknowledged that she should have sanitized her hands after removing her gloves to prevent cross-contamination. Both the DON and RDCO emphasized the importance of sanitizing hands immediately after glove removal to prevent infection and cross-contamination, aligning with the facility's policy that states hand hygiene must be performed after glove removal.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bessemer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehaven Health And Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Baron House Of Hueytown | 2.4 mi | ★★★★★ | 0 | 0 |
| Self Skilled Nursing & Rehab | 3.5 mi | ★★★★★ | 0 | 0 |
| Redmont Health And Rehabilitation Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Caregivers Of Pleasant Grove, Inc | 4 mi | ★★★★★ | 0 | 0 |
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