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 Northridge Health Center, The during CMS and state inspections, most recent first.
Two CNAs provided incontinence care to a resident with bowel and bladder incontinence, removed their gloves, and left the room with soiled items without performing hand hygiene. One CNA then obtained clean linen for the resident without washing hands, while the other used hand sanitizer only after returning to the room. Both confirmed in interviews that they did not perform hand hygiene after care, contrary to facility policy and expectations.
The facility did not promptly notify physicians or conduct timely assessments after residents experienced significant changes in condition, including exposure to illicit drug use and adverse reactions to medication. In two cases, staff failed to immediately assess or inform medical providers about a resident exposed to smoke from illicit substances and another resident who vomited after starting antibiotics, contrary to facility policy.
A resident with a history of polysubstance use, including alcohol and cocaine abuse, as well as diabetes and morbid obesity, was found using illicit substances in the facility. Despite this, no care plan with goals or interventions addressing substance use was developed or implemented, as confirmed by staff review.
A resident with significant physical and cognitive impairments was not provided timely assistance with ADLs and incontinence care, remaining in soiled clothing and a saturated brief for several hours. Staff confirmed it was routine to delay changing until after lunch, despite care plans and policy requiring checks and changes every two hours and as needed. Observations noted the resident's clothing was soiled, and skin was red and indented from prolonged exposure to moisture.
Two residents were affected when staff failed to properly monitor one resident for drug-related behaviors after illicit drug use was observed, and did not timely assess or notify providers regarding the other resident's exposure to the substance, despite the latter's significant respiratory and cognitive conditions.
A resident with severe respiratory conditions did not receive continuous oxygen therapy as ordered, as the nasal cannula was found on the floor and not in use. An LPN was initially unaware of the oxygen order and, after reconnecting the tubing, set the concentrator to the incorrect flow rate, contrary to physician orders and facility policy.
Two residents with diabetes did not receive insulin injections according to physician orders and facility policy, as LPNs failed to properly prime insulin pens before administration. Observations and interviews confirmed that insulin pens were either primed incorrectly or not at all, despite clear facility protocols requiring priming with the needle attached before each use.
The facility failed to educate residents and staff on the COVID-19 vaccine, including its risks and benefits, affecting five residents and seven staff members. Residents with cognitive impairments and intact cognition had refusals documented without prior education. Staff were offered the vaccine without educational information, contrary to facility policy.
The facility failed to provide adequate staffing, affecting resident care. A resident with diarrhea was left unchanged during meal service, causing distress. Another resident, dependent on staff for hygiene, was not repositioned or changed as required, remaining in a chair all day. A third resident missed scheduled showers due to staffing shortages. The facility's staffing ratios consistently fell short of their own requirements, particularly on weekends.
The facility's administration failed to investigate staff mistreatment reports, maintain accurate medical records, and ensure adequate staffing. Infection control practices were inadequate during a COVID-19 outbreak, with failures in contact tracing, reporting, and testing. Residents were not treated with respect, and care conferences and transfer notices were neglected.
The facility failed to implement effective infection control practices during a COVID-19 outbreak, affecting multiple residents and staff. There was a lack of timely contact tracing, testing, and reporting to the Local Health Department. Additionally, proper infection control procedures were not followed during tracheostomy care for a resident, increasing the risk of infection.
The facility failed to maintain accurate medical records and implement care plans for several residents. A resident did not receive a prescribed splint, while another was left in a chair for extended periods without repositioning or wearing ted hose. Hospice services and physician notifications were inadequately documented for a resident, and COVID-19 testing records were missing for others. These deficiencies indicate lapses in record-keeping and care plan adherence.
The facility failed to conduct routine care plan meetings for residents in 2024, affecting a resident with significant medical conditions. The last care plan meeting for this resident was in August 2023, and the facility did not hold required meetings for all residents, except those admitted after November 2024. This was confirmed by staff and violated the facility's policy.
The facility failed to monitor residents on psychotropic medications for adverse effects and behaviors. A resident had no care plan for anxiety and depression despite being on multiple psychotropic medications, with no documentation of monitoring. Another resident, cognitively intact, was on antidepressants and antipsychotics without evidence of behavior or medication monitoring. A third resident with dementia and bipolar disorder had no documentation of side effects or behaviors for their medications. The facility's policy required such documentation, which was not followed.
The facility failed to ensure proper medication administration and storage for two residents. One resident was left with Tylenol tablets unattended, unaware of the contents, while another resident, not assessed for self-administration, was found with multiple medications without supervision. Nurses confirmed the lack of observation during medication administration, indicating a lapse in protocol.
The facility failed to treat residents with dignity and respect, affecting two residents. One resident reported an LPN's sarcastic and rude behavior, while another was subjected to forceful medication administration. Staff were aware of the LPN's behavior but did not report it, believing the administration would not act.
The facility failed to ensure call lights were within reach for three residents, all of whom had specific care plans due to their risk factors such as dementia, bipolar disorder, and brain damage. Observations revealed that the call lights were on the floor and inaccessible, which was confirmed by a CNA. The facility's policy mandates that staff ensure call lights are accessible during each interaction, which was not followed in these instances.
A facility failed to notify a resident's family of a significant decline in the resident's condition, as required by policy. The resident, with diagnoses including pneumonia and respiratory failure, was in respiratory distress and later passed away. Staff interviews revealed a lack of communication and documentation regarding family notification, with the LPN assuming the ADON would inform the family, which did not happen.
A facility failed to implement a comprehensive care plan for a resident, neglecting to address their depression, anxiety, behaviors, and use of psychotropic medications. Despite having physician orders for medications like quetiapine, Zoloft, and Depakote, these were not reflected in the care plan. An MDS Nurse confirmed the absence of a care plan for these conditions, contrary to the facility's policy requiring comprehensive care plans to maintain residents' well-being.
A resident, dependent on staff for bathing due to a lower extremity impairment, was not offered showers as scheduled, receiving only four out of eleven planned showers. Staff interviews revealed that staffing shortages led to this deficiency, despite facility policy requiring regular assistance with activities of daily living.
The facility failed to implement physician-ordered compression socks for a resident and did not timely address another resident's excessive sweating, leading to skin damage. Observations and staff interviews revealed non-compliance with care plans and inadequate documentation of the residents' conditions.
A resident with a left hand contracture did not receive the prescribed palm protective splint to maintain mobility, as staff were unable to locate it. Observations confirmed the resident was not wearing the splint during the day or at night, contrary to physician orders. An LPN verified the absence of the splint or an alternative like a rolled-up towel.
The facility failed to prevent a fall for a resident who required two-person assistance, resulting in a skin tear, and did not conduct a thorough investigation into another resident's fall. The first resident rolled out of bed during a bed bath by a single CNA, contrary to care plan requirements. The second resident's fall investigation lacked necessary witness statements, and there were discrepancies in the reported cause of the fall.
The facility failed to provide adequate care for residents with indwelling catheters and those requiring incontinence care. A resident was left in a soiled state for hours, while another was not changed or repositioned as required, leading to saturated briefs and skin redness. Additionally, catheter tubing was not secured for two residents, increasing the risk of complications. These issues highlight systemic problems in staffing and care provision.
A facility failed to prime insulin pens before administration, leading to a significant medication error for a resident with diabetes. An LPN administered insulin without priming the pen-injectors, contrary to facility policy and Medscape guidance, affecting one of five residents reviewed. The facility identified 14 residents receiving insulin via pen-injectors.
The facility failed to provide written notices of transfer or discharge to residents when they were sent to the hospital, affecting four residents. The deficiency was confirmed through record reviews, staff interviews, and policy reviews. The residents involved had intact cognition, and the facility's policy required a notice of transfer for emergency transfers or discharges, which was not adhered to.
The facility failed to provide a bed hold notice to residents during hospital transfers, affecting multiple residents with intact cognition. Despite a policy requiring the notice at the time of transfer, the facility did not adhere to this, as confirmed by record reviews and staff interviews.
A resident with chronic pain did not receive her prescribed oxycodone for several days due to the facility's failure to ensure a timely refill. Despite the resident's reminders, the medication was unavailable until a new prescription was obtained. The facility's policy on medication administration was not followed, leading to a deficiency.
A facility failed to document the administration of oxycodone for a resident with multiple health issues, including chronic pain. The MAR lacked entries for several dates when the medication was signed out, contrary to the facility's policy requiring documentation in both the MAR and narcotic book. This deficiency was confirmed by the ADON and investigated under a complaint.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident, with multiple diagnoses including paraplegia and traumatic brain injury, had his call light wrapped around a grab bar and out of reach. Another resident, with hemiplegia and cerebral infarction, was without a call light for a week. Staff interviews confirmed the call lights were not accessible, contrary to facility policy.
Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
Staff failed to maintain proper infection control practices after providing care to a resident who was dependent for toileting hygiene and incontinent of bowel and bladder. Two CNAs provided incontinence care, changed the resident's brief, pants, and linen, and then removed their gloves. Both CNAs left the room with soiled items without performing hand hygiene, either by washing their hands or using hand sanitizer. One CNA proceeded to obtain clean linen from a cart used for all residents and returned to the resident's room to place the linen on the bed, still without performing hand hygiene. The other CNA eventually used hand sanitizer, but only after returning to the room following disposal of soiled items. Both CNAs confirmed in interviews that they did not perform hand hygiene after providing peri-care and before moving on to other tasks or residents. Interviews with the DON and Regional Director of Clinical Services confirmed that staff were expected to perform hand hygiene before entering a resident's room, after providing care, and before leaving the room. Review of the facility's hand hygiene policy indicated that hand hygiene is required after direct contact with residents, after contact with bodily fluids, after removing gloves, and before handling clean linen. The policy also stated that glove use does not replace hand hygiene. The failure to follow these procedures was observed and confirmed through staff interviews and policy review, affecting the infection control program for all residents in the facility.
Failure to Notify Physician and Assess Residents After Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to physicians regarding changes in residents' conditions, as well as appropriate assessment and monitoring following significant incidents. In one instance, a resident with a history of substance use was found by a CNA and two LPNs to be smoking an illicit substance in his bathroom. The staff observed the resident using drug paraphernalia and blowing smoke in the face of a nurse. The police and facility administration were notified, and the paraphernalia was confiscated. However, there was no documentation of any restrictions or interventions implemented to prevent further drug use by the resident, nor was there evidence of increased monitoring to protect other residents, including the roommate who was present during the incident. The roommate, who had multiple respiratory diagnoses and required continuous oxygen therapy, was not assessed immediately after the exposure to the illicit substance. The initial assessment of this resident was not completed until the following day, and vital signs taken at that time showed the lowest blood pressure recorded for the resident in the reviewed timeframe. There was no documentation that the physician or nurse practitioner was notified of this abnormal finding. Interviews confirmed that the expected protocol of immediate assessment and notification was not followed, and the resident was not awakened or physically assessed during the night following the incident, despite the potential for exposure to harmful substances. In another case, a resident receiving antibiotic therapy for a toe infection experienced nausea and vomiting after starting the medication. The resident reported vomiting to a CNA, who disposed of the vomit but did not inform the charge nurse until prompted during an interview. The nurse was unaware of the resident's symptoms until later in the morning, and there was no evidence of timely assessment or physician notification regarding the adverse reaction. The facility's policy required prompt notification of changes in condition, but this was not adhered to in these cases.
Failure to Develop Care Plan for Substance Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan to address the medical and psychosocial needs of a resident with a history of polysubstance use, including alcohol abuse, cocaine use, type II diabetes, and morbid obesity. Despite documentation in the medical record and incident file indicating the resident's ongoing substance use, including an incident where the resident was found smoking an illicit substance in his room, there were no care plans with measurable goals or interventions related to substance use. This omission was confirmed by a social worker who verified the absence of such care planning in the resident's medical record.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
Staff failed to provide timely care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for most ADLs due to multiple medical conditions, including cerebral infarction, muscle weakness, congestive heart failure, contractures, moderate dementia with agitation, and hemiplegia. The resident was assessed as always incontinent of bowel and bladder, required two-person assistance for toileting, dressing, bathing, and hygiene, and was to be checked and changed every two hours and as needed per the care plan and facility policy. On the day of observation, the resident was placed in a chair in the dining room at 7:00 A.M. and was not checked or changed for incontinence until after lunch, despite being visibly soiled and wet for several hours. Multiple observations confirmed the resident remained in the same soiled clothing throughout the morning and early afternoon, with dried food and liquid on her shirt and wet pants. Staff interviews confirmed it was routine not to change the resident until after lunch, contrary to the care plan and facility policy. Upon being changed, the resident's brief was heavily saturated with urine, there was a foul odor, and the resident's skin showed redness and indentations from the soiled brief.
Failure to Monitor and Assess Residents Following Illicit Drug Use Incident
Penalty
Summary
The facility failed to properly monitor and assess two residents in relation to illicit drug use and exposure. One resident with a history of bipolar disorder, cocaine use, and alcohol abuse was observed by staff actively smoking an illicit substance in his bathroom. Staff, including a CNA and two LPNs, witnessed the resident using drug paraphernalia and attempting to conceal the substance. Despite the incident, there was no documentation of restrictions or interventions implemented to prevent further drug use or to monitor the resident for subsequent behaviors. The resident refused to sign a behavior contract and was discharged shortly after the incident. The resident's roommate, who had multiple chronic conditions including COPD, dementia, and chronic respiratory failure, was in close proximity to the incident. Despite the exposure to smoke from the illicit substance, there was no immediate assessment or documentation of the roommate's condition following the event. The initial assessment of the exposed resident was not completed until the following day, and it revealed a notably low blood pressure reading. There was no documentation that the physician or nurse practitioner was notified of this abnormal finding, and the staff could not confirm if any notification occurred. Interviews with facility staff, including the DON, LPNs, and the CNP, confirmed that no timely assessment or monitoring was conducted for the exposed resident. The CNP and physician both stated that an immediate assessment and ongoing monitoring would have been expected following such exposure, especially given the resident's respiratory conditions. The lack of prompt assessment and failure to notify medical providers of abnormal vital signs contributed to the deficiency identified during the survey.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide supplemental oxygen to a resident as ordered by the physician. The resident, who had multiple respiratory diagnoses including anoxic brain damage, MRSA pneumonia, COPD, asthma, emphysema, and both acute and chronic respiratory failure, was dependent on staff for all activities of daily living and was to receive continuous oxygen therapy at two liters per minute via nasal cannula. During observation, the resident was found lying in bed with the oxygen concentrator running, but the nasal cannula was on the floor and not in use, resulting in the resident not receiving oxygen as ordered. When the primary care LPN was questioned, she was initially unaware of the resident's oxygen order and did not address the misplaced nasal cannula. Upon review of the physician's orders, the LPN confirmed the need for continuous oxygen at two liters per minute. After reconnecting the oxygen tubing and cannula, it was discovered that the concentrator was set to 1.5 liters per minute, not the prescribed two liters. The facility's policy required staff to verify and follow physician orders for oxygen administration, which was not done in this instance.
Failure to Administer Insulin per Policy and Physician Orders
Penalty
Summary
The facility failed to ensure that insulin was administered according to physician orders and facility policy for two residents who required insulin injections via insulin pen. For one resident with type two diabetes, an LPN primed the insulin pen before attaching the needle, rather than after, and then administered the insulin without repriming, contrary to policy. For another resident with type one diabetes, an LPN administered insulin without priming the pen at all, as confirmed by both observation and staff interview. In both cases, the facility's policy required priming the insulin pen with the needle attached and dialing two units before each injection to ensure correct dosing. Both residents involved were cognitively intact and had documented care plans and physician orders specifying the administration of insulin via pen-injector. The facility's policy, reviewed and dated July 2024, clearly outlined the steps for proper insulin pen priming and administration, which were not followed by the nursing staff. These failures were identified through direct observation, staff interviews, and review of medical records and facility policy.
Failure to Educate Residents and Staff on COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that residents and staff were adequately educated on the COVID-19 vaccine, including its risks, benefits, and side effects. This deficiency was identified through a review of medical records and personnel files, which revealed that five residents and seven staff members had not received the necessary education. For instance, Resident #57, who had severe cognitive impairment, expressed a desire for the COVID-19 vaccine, but there was no documentation of education provided. Similarly, Resident #14, with impaired cognition, had a note from their power of attorney declining the vaccine, yet no educational information was documented. Other residents, including those with intact cognition, also had refusals documented without evidence of prior education. The personnel files for seven staff members, including CNAs and a Maintenance Director, showed no documentation of education regarding the COVID-19 vaccine. An interview with the Assistant Director of Nursing (ADON) confirmed that while the vaccine was offered at a staff meeting, no educational information was provided. The ADON also verified that residents were offered the vaccine without being informed of its benefits, risks, and side effects. The facility's policy stated that education should be provided before offering the vaccine, but this was not adhered to, leading to the deficiency.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, affecting three specific residents and potentially impacting all 74 residents. Resident #181, who was cognitively intact and required assistance with toileting hygiene, experienced delays in receiving incontinence care. On one occasion, despite having diarrhea, Resident #181 was not changed promptly due to staff being occupied with meal service. This resulted in the resident sitting in soiled conditions for an extended period, causing distress and embarrassment. Resident #55, who was severely cognitively impaired and dependent on staff for toileting hygiene, was not changed or repositioned as required. Despite physician orders to check and change the resident every two hours, observations revealed that Resident #55 remained in a Broda chair for extended periods without receiving necessary care. The resident's wife confirmed that he was often left in the chair all day without being laid down or changed, highlighting a significant lapse in care. Resident #182, admitted for recuperation from a shattered femur, was scheduled for showers twice a week but was only offered a shower four times out of the scheduled eleven. Interviews with staff confirmed that insufficient staffing levels often led to missed showers, as there was not enough time to attend to all residents' needs. Additionally, the facility's staffing ratios consistently fell short of the requirements outlined in their Facility Assessment, particularly during weekends, further exacerbating the issue of inadequate care.
Deficiencies in Administration and Infection Control
Penalty
Summary
The administration team of the facility failed to ensure proper investigation and response to reports of staff mistreatment, maintain accurate medical records, and provide adequate staffing. There were instances where staff and resident reports of mistreatment were dismissed without investigation, and issues with the accuracy of residents' medical records were not identified. Additionally, the facility did not maintain adequate staffing levels as per their assessment, particularly during weekends, which affected the care provided to residents. The facility's infection control practices were inadequate, particularly during a COVID-19 outbreak. The administration did not ensure timely contact tracing, reporting to the local health department, or testing of residents and staff according to CDC guidelines. This failure affected numerous residents and staff, and there was a lack of education provided to residents and staff about the COVID-19 vaccine. The facility also failed to conduct routine care conferences with residents and their representatives and did not provide written notices of transfer and bed hold notices when residents were transferred to the hospital. Furthermore, there were reports of residents not being treated with respect and dignity by certain staff members, which were not addressed by the administration. Specific incidents included a nurse being sarcastic and rude to residents and another staff member demanding and shoving medications into a resident's mouth. The administration was unaware of these issues, and there was a lack of follow-up on concerns related to resident treatment. The administration's inaction and failure to perform their responsibilities contributed to these deficiencies.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement effective infection control practices during a COVID-19 outbreak, affecting 26 residents and three staff members. The facility did not conduct timely contact tracing or testing for staff and residents who were close contacts of COVID-19 positive individuals, as per CDC guidelines and facility policy. This oversight led to a significant spread of COVID-19 within the facility, with multiple residents and staff testing positive over a period of time. The facility also failed to report the outbreak to the Local Health Department (LHD) in a timely manner, as required by law. Additionally, the facility did not adhere to proper infection control procedures during tracheostomy care for a resident with a tracheostomy, cerebral infarction, and acute respiratory failure. The LPN responsible for the care did not follow enhanced barrier precautions, such as washing hands or wearing a gown and mask, which are essential to prevent infection. This lack of adherence to protocol was observed during a tracheostomy suctioning procedure, where sterile technique is crucial to avoid contamination. Interviews with staff and residents revealed a lack of communication and documentation regarding COVID-19 testing and contact tracing. Some staff members were not tested during the outbreak, and there was no documentation of testing for certain residents on specified dates. The facility's Director of Nursing and Assistant Director of Nursing admitted to not maintaining proper records and not following the facility's policy for testing and contact tracing. The Local Health Department confirmed that the facility did not report the outbreak until several days after it began, and no line listing of positive cases was submitted as required.
Inaccurate Medical Records and Care Plan Implementation
Penalty
Summary
The facility failed to ensure the accuracy and factuality of medical records for several residents, as observed during the annual survey. For Resident #26, there was a discrepancy between the documented use of a palm protective splint and the actual practice. The Treatment Administration Record (TAR) indicated that the splint was applied and removed as per the physician's orders, but observations and interviews with the resident and staff revealed that the splint had not been used for months. Licensed Practical Nurse (LPN) #367 admitted to signing off on the TAR without verifying the splint's application. Resident #55's care was also inadequately documented and executed. Despite physician orders to check and change the resident every two hours and limit time in a Broda chair to four hours, observations showed the resident remained in the chair for extended periods without being repositioned or changed. The resident's wife and staff interviews confirmed the lack of adherence to care plans, and the Medication Administration Record (MAR) and TAR inaccurately reflected that all orders were completed. Additionally, the resident was not wearing ted hose as required, and staff failed to ensure their availability. For Resident #177, there was a lack of documentation regarding hospice services and physician notification when the resident began spitting up tube feeding. The medical record did not reflect any hospice orders or discussions with the family, and the physician was not informed of the resident's condition change. Other residents, including Residents #54, #57, #35, #38, and #53, also had discrepancies in their medical records, such as missing documentation of COVID-19 testing and moisture-associated skin damage (MASD) not being recorded or monitored as required. These deficiencies highlight significant lapses in maintaining accurate and complete medical records in accordance with professional standards.
Failure to Conduct Routine Care Plan Meetings
Penalty
Summary
The facility failed to conduct routine and scheduled care plan meetings for residents and/or their representatives throughout 2024. This deficiency was identified through resident and staff interviews, record reviews, and a review of the facility's policy. Specifically, one resident, identified as Resident #51, did not have a care plan meeting in 2024, despite being moderately cognitively impaired and having significant medical conditions, including a displaced midcervical fracture of the left femur, atrial fibrillation, and hemiplegia and hemiparesis following a cerebral infarction. The last documented care plan meeting for this resident was in August 2023, and the resident confirmed not being invited to any care plan meetings in 2024. Further investigation revealed that the facility did not hold annual and quarterly care plan meetings for all residents, except for those admitted after November 2024. This was confirmed by a Licensed Social Worker and the Regional Director of Clinical Services, who acknowledged that care plan meetings were not consistently completed as required. The facility's policy mandates that care plans be discussed with residents or their representatives at regularly scheduled intervals, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure proper monitoring of residents on psychotropic medications for adverse consequences and behaviors. This deficiency affected three residents out of five reviewed for unnecessary medications, with a total of 48 residents receiving psychotropic medications in a facility census of 74. For Resident #61, there was no care plan in place for anxiety, depression, behaviors, or the use of antipsychotic and psychotropic medications. Despite being prescribed quetiapine, Zoloft, and Depakote, there was no documentation of monitoring for potential adverse effects from these medications. The Regional Nurse confirmed the lack of documentation and stated that monitoring should have been recorded in the medication administration record or treatment administration record. Similarly, Resident #13, who was cognitively intact, was prescribed Duloxetine and Quetiapine Fumarate for psychosis, depression, and anxiety. However, there was no evidence of behavior monitoring or monitoring of medications for efficacy and adverse consequences. The Regional Nurse verified that behavior monitoring should have been documented but was not completed. For Resident #42, who had diagnoses including dementia with agitation and bipolar disorder, there was no documentation of side effects or behaviors for the prescribed Olanzapine and Mirtazapine. The Registered Nurse confirmed the absence of documentation, which should have been recorded daily. The facility's policy required documentation of the response to medications, including progress towards goals and the presence or absence of adverse consequences, in the resident's medical record.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper medication administration and storage for two residents, leading to deficiencies in medication management. Resident #181, who was admitted with a diagnosis that included pain management, had a physician's order for Tylenol 325 mg to be administered as needed. However, during an observation, it was found that a pill cup containing two Tylenol tablets was left unattended on the resident's bedside table. The resident was unaware of the contents, and the nurse had left the room without observing the resident taking the medication. The nurse later confirmed that she should have observed the resident consuming the medication before leaving. Similarly, Resident #24, who was admitted with diagnoses including hallucinations and altered mental status, was found holding a cup with approximately eight medication capsules/tablets without any staff supervision. The resident, who was not assessed as capable of self-administering medications, called out for apple juice to take the medications. The nurse confirmed that the medications were given without observing the resident taking them, which was against the protocol. This lack of supervision and failure to ensure proper medication administration was verified by the nurse, highlighting a significant lapse in the facility's medication management practices.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, affecting two residents. Resident #13, who was cognitively intact, reported that an LPN frequently made sarcastic and rude comments and was suspected of cursing at her. This behavior was corroborated by another staff member who reported that the LPN often cursed and yelled at residents, although this was not reported to the administration due to a belief that no action would be taken. Resident #74, who also had intact cognition, was subjected to inappropriate treatment by the same LPN. A former LPN witnessed the LPN demanding the resident to open their mouth for medication, pushing the resident, and forcefully administering the medication. Despite these observations, the facility's administration was unaware of these issues, indicating a lack of communication and reporting among staff regarding the LPN's behavior.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, which is a critical aspect of their care plans due to their risk factors. Resident #42, who has dementia, bipolar disorder, and decreased safety awareness, was observed with their call light on the floor at the bottom of the bed, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the call light was out of reach and that staff are responsible for ensuring call lights are accessible to residents. Similarly, Resident #14, who is at risk for falls due to dementia and incontinence, was found with their call light cord on the floor by the wall, out of reach. This was also verified by the same CNA. Additionally, Resident #34, who has brain damage and seizures, was observed with their call light out of reach and expressed a need for pain medication. The CNA confirmed the call light was on the floor and inaccessible. The facility's policy requires staff to ensure call lights are within reach during each interaction with residents, which was not adhered to in these cases.
Failure to Notify Family of Resident's Decline
Penalty
Summary
The facility failed to notify a resident's family of a significant decline in the resident's condition, which is a requirement under their policy. The resident, who had diagnoses including pneumonia, hypertension, and acute and chronic respiratory failure with hypoxia, was noted to be in respiratory distress with a pulse oximetry level of 80 percent. Despite interventions such as suctioning and aerosol treatment, the resident's condition did not improve significantly, and the resident eventually passed away. There was no documentation that the family was informed of the resident's decline. Interviews with the staff revealed that there was a lack of communication and documentation regarding the notification of the resident's family. The LPN involved in the care of the resident assumed that the ADON would notify the family, but this did not occur. Additionally, the DON and ADON confirmed that they did not document the care provided or notify the family of the resident's condition change. This oversight was a violation of the facility's policy on notifying family members of significant changes in a resident's condition.
Failure to Implement Comprehensive Care Plan for Resident's Mental Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, specifically addressing their depression, anxiety, behaviors, and the use of psychotropic medications. The resident, who was admitted with diagnoses including delirium, dementia, psychotic disturbance, mood disturbance, and major depressive disorder, did not have these conditions adequately addressed in their care plan. Despite having physician orders for medications such as quetiapine, Zoloft, and Depakote to manage these conditions, the care plan initiated on 11/13/24 did not reflect these critical aspects of the resident's care. An interview with the MDS Nurse revealed that the nurse, who had been working at the facility for three weeks, had not reviewed all previous care plans and confirmed the absence of a care plan for the resident's mental health conditions and medication use. The facility's policy on comprehensive care plans, revised on 06/01/24, mandates that care plans should include services to maintain the resident's highest practicable physical, mental, and psychosocial well-being, which was not adhered to in this case.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing and showering, to a resident who was dependent on staff for these services. The resident, who was cognitively intact and had an impairment on one side of the lower extremity, was admitted for orthopedic aftercare following a shattered femur. Despite being scheduled for showers twice a week, the resident was only offered a shower four times out of the eleven scheduled instances. This lack of care was confirmed through interviews with the resident and staff, as well as a review of the facility's records. The facility's policy required that care and services be provided for activities of daily living, including bathing, but this was not adhered to in the case of the resident. Interviews with staff revealed that showers were not consistently offered due to staffing shortages, which led to the resident not receiving the scheduled showers. The facility's documentation corroborated the resident's account of not being offered a shower for an extended period after admission, highlighting a significant lapse in the provision of care as per the facility's policy.
Failure to Implement Physician Orders and Address Skin Issues
Penalty
Summary
The facility failed to ensure that physician-ordered compression socks were implemented for Resident #55. Despite orders to apply TED hose in the morning and remove them at night for deep vein thrombosis prophylaxis, observations revealed that Resident #55 did not have the TED hose on during multiple checks throughout the day. Staff interviews confirmed that Resident #55 had not been wearing TED hose for the past six months, despite the medical record indicating that the orders were signed as completed. The Registered Nurse Supervisor acknowledged the absence of TED hose in the resident's room and admitted to not having provided them from stock. The facility also failed to timely provide care and treatment for Resident #54's excessive sweating, which led to moisture-associated skin damage (MASD). Resident #54, who was dependent on staff for activities of daily living and had an indwelling catheter, was observed to have a rash and excoriated areas on the buttocks due to excessive sweating. Despite the spouse's concerns and the visible skin issues, there was no documentation of MASD in the medical record. Interviews with staff revealed that the resident's condition was known but not adequately documented or addressed. The deficiency represents non-compliance as the facility did not adhere to physician orders for compression socks and failed to document and manage the skin condition of Resident #54. The lack of proper documentation and follow-through on care plans contributed to the ongoing issues with both residents, highlighting a gap in the facility's care and service delivery.
Failure to Provide Prescribed Splint for Resident's Hand Contracture
Penalty
Summary
The facility failed to ensure that a resident received the appropriate treatment and services to maintain or improve mobility according to physician orders. Resident #26, who was admitted with a diagnosis of left hand contracture, was supposed to have a palm protective splint applied to her left hand in the PM and removed in the AM. However, observations and interviews revealed that the resident was not wearing the splint as prescribed. On one occasion, the resident was seen propelling herself in a wheelchair without the splint, and she reported that staff had not put it on for months because they were unable to find it. Further observations and interviews confirmed that the resident was not wearing the splint at night as required. A Licensed Practical Nurse verified that the resident should have had a splint or a rolled-up towel in her hand at night, but neither was in place. The resident expressed a desire to wear the splint if it could be found, indicating a lapse in the facility's adherence to the care plan and physician orders for maintaining the resident's range of motion.
Failure to Prevent Falls and Conduct Thorough Investigations
Penalty
Summary
The facility failed to prevent an avoidable fall with minor injury for a resident and did not ensure fall interventions were in place for another resident at risk of falling. One resident, who was totally dependent on staff for activities of daily living (ADLs) and had a potential risk for falls, rolled out of bed while being given a bed bath by a single certified nursing aide (CNA), despite the care plan requiring two-person assistance. This resulted in a large skin tear on the resident's left forearm. Observations later revealed that the resident's bed was left in a high position, contrary to the care plan's directive to keep it in the lowest position while occupied. Another resident experienced a fall while attempting to open a stuck dresser drawer, which was not thoroughly investigated. The fall investigation lacked witness statements from the CNA who found the resident and from the resident himself. The resident later reported falling out of a Hoyer lift due to a broken strap, which was not initially documented. The Director of Nursing confirmed the absence of necessary statements, and the CNA involved denied using the Hoyer lift at the time of the incident. The facility's policy on fall prevention and management requires that each resident be assessed for fall risk and that preventative measures be implemented and monitored. However, the facility did not adhere to these protocols, as evidenced by the lack of proper staffing during the resident's bed bath and the incomplete investigation into the other resident's fall. These deficiencies were identified during a complaint investigation, highlighting non-compliance with established fall prevention procedures.
Deficiencies in Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide adequate care for residents with indwelling catheters and those requiring incontinence care. For Resident #181, the facility did not ensure timely incontinence care, as the resident was left in a soiled state for several hours. Despite the resident's cognitive awareness and ability to communicate her needs, staff did not respond promptly to her call light, and she was forced to wait until after meal service to be changed. This delay in care was corroborated by interviews with the resident, her husband, and staff members, highlighting a lack of sufficient staffing during critical times. Resident #55, who was severely cognitively impaired and dependent on staff for all activities of daily living, was also neglected in terms of incontinence care. Despite physician orders to check and change the resident every two hours and limit time in a Broda chair, the resident was left in the chair for extended periods without being changed. Observations revealed that the resident's brief was saturated with urine, and his skin was red, indicating prolonged exposure to moisture. Staff interviews confirmed that the resident was not laid down or changed as required, and there was a misunderstanding about the hospice aide's role in providing care. Additionally, the facility failed to secure the catheter tubing for Residents #5 and #47, increasing the risk of catheter dislodgement and potential complications. Observations confirmed that the tubing was not secured, and staff acknowledged the oversight. These deficiencies were identified during a complaint investigation, indicating systemic issues in the facility's ability to provide consistent and timely care for residents with specific medical needs.
Failure to Prime Insulin Pens Leads to Medication Error
Penalty
Summary
The facility failed to ensure that insulin pens were primed according to manufacturer instructions before administration, resulting in a significant medication error. This deficiency was identified during a review of medication administration for a resident diagnosed with type two diabetes mellitus with hyperglycemia. The resident was ordered to receive Lantus Solostar and Novolog via pen-injectors. During an observation, an LPN administered insulin to the resident without priming the pen-injectors, which is necessary to remove air and ensure the correct dosage. The facility's policy on medication administration, as well as Medscape guidance, both emphasize the importance of priming insulin pens to avoid air bubbles and ensure accurate dosing. The LPN confirmed in an interview that she did not prime the insulin pens as required. This oversight affected one of the five residents reviewed for medication administration, with the facility identifying a total of 14 residents who receive insulin via pen-injectors.
Failure to Provide Written Notices of Transfer/Discharge
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to residents when they were sent to the hospital, affecting four residents who were reviewed for transfer or discharge. The facility identified a total of 32 residents who were discharged to the hospital since May 2024. The deficiency was confirmed through record reviews, staff interviews, and policy reviews. The residents involved had intact cognition, as revealed by their quarterly Minimum Data Set (MDS) assessments. Resident #78 was discharged to the hospital on three occasions, Resident #46 on five occasions, Resident #76 on one occasion, and Resident #44 on three occasions, without receiving the required written notices. Interviews with the Regional Administrator confirmed that the facility did not provide the necessary documentation to the residents or their representatives. The facility's policy, revised in August 2022, stated that a notice of transfer should be provided for emergency transfers or discharges, which was not adhered to in these cases.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a notice of the bed hold policy when they were transferred to the hospital, affecting four residents who were reviewed for transfer/discharge. The facility identified that 32 residents had been discharged to the hospital since May 2024, but none were provided with the required bed hold notice. This deficiency was confirmed through record reviews, staff interviews, and policy reviews. The residents involved had intact cognition, as revealed by their quarterly Minimum Data Set (MDS) assessments. The medical records for the affected residents showed multiple instances of hospital transfers without documentation of the bed hold notice being provided. Interviews with the Regional Administrator confirmed that the facility did not provide the bed hold policy to the residents or their representatives during these transfers. The facility's policy, revised in June 2024, required that the bed hold policy be given at the time of transfer for hospitalization, but this was not adhered to, leading to the deficiency.
Failure to Provide Timely Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that narcotic pain medication was available for a resident, leading to a deficiency in pharmaceutical services. Resident #27, who had multiple diagnoses including chronic pain, was prescribed oxycodone to be taken as needed. However, the facility did not ensure the timely refill of this medication, resulting in the resident going without her prescribed narcotic pain relief for several days. The resident's medical record indicated that she consistently took the medication in the evenings, and the last dose was administered on the morning of June 14, 2024. Despite the resident's reminders to the nursing staff about the need for a new prescription, the medication was not available until June 20, 2024. Interviews with the resident and staff revealed that the pharmacy required a new prescription to dispense the medication, but the on-call physician initially refused to call in the script outside of office hours. The Assistant Director of Nursing acknowledged that the nurse should have notified the pharmacy to refill the medication when there were five pills left. The facility's policy on medication administration stated that medications should be administered as ordered by the physician and in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00154355.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to accurately document the administration of a narcotic pain medication, oxycodone, in the Medication Administration Record (MAR) for a resident. This deficiency was identified through a review of the medical records, staff interviews, and facility policy. The resident, who had multiple diagnoses including acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer, chronic pain, and cellulitis, was prescribed oxycodone 5 mg to be administered every four hours as needed. However, the MAR lacked documentation for several dates in May and June when the medication was signed out for administration. The Assistant Director of Nursing confirmed that narcotic medications should be documented both on the Controlled Drug Record/Disposition Form and in the MAR. The facility's policy on medication administration, dated August 22, 2022, requires that medications be signed on the MAR after administration and, if controlled substances, also in the narcotic book. The failure to document the administration of oxycodone as per the facility's policy led to this deficiency, which was investigated under Complaint Number OH00154355.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that resident call lights were within reach for two residents, affecting their ability to request assistance. Resident #32, who has diagnoses including acute respiratory failure, paraplegia, traumatic brain injury, epilepsy, and type II diabetes, was observed with his call light wrapped around a grab bar and out of reach. Despite having intact cognition, Resident #32 is dependent on staff for bed mobility, transfers, and hygiene. His care plan specifically included the intervention to keep the call light within reach. Resident #69, who has hemiplegia, cerebral infarction, and other conditions, was found without a call light for a week, according to his statement. He requires substantial assistance for transfers and bed mobility and is dependent on staff for toileting and showering. During an observation, Resident #69's call light was found under the foot of his bed, and Resident #32's call light was out of reach. Interviews with staff revealed that the call lights were not in reach, and there was confusion about which staff member was responsible for ensuring the call lights were accessible. The facility's policy requires staff to ensure call lights are within reach during each interaction with residents, but this was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 663 citations issued within 25 miles in the last 12 months — including the 5 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Ridgeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenue At North Ridgeville | 1.6 mi | ★★★★★ | 7 | 0 |
| O'neill Healthcare North Ridgeville | 2 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Elyria | 4 mi | ★★★★★ | 0 | 0 |
| Avon Oaks Nursing Home | 4.2 mi | ★★★★★ | 8 | 0 |
| St Mary Of The Woods | 4.6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.