Inspection Reports for
Northern Pines Rehabilitation and Nursing

The complaint investigation revealed failures in background checks, timely reporting and investigation of abuse allegations, and medication administration errors. Some incidents involved delayed or missing reports to the State Survey Agency and incomplete investigations. The facility acknowledged prior issues with reporting and investigation due to multiple administrators and staff turnover.

The facility failed to complete background checks on 6 of 9 sampled employees prior to their start date, failed to report two allegations of abuse within the required two-hour timeframe and failed to report investigation findings timely for others. Additionally, the facility did not fully investigate abuse allegations for 5 of 12 sampled residents and failed to ensure nursing staff followed professional standards for medication administration, resulting in administration of a controlled substance without a current physician's order on three separate days.

The complaint involved incidents between residents #1 and #11 occurring on 9/14/24 and 9/17/24 that were not identified or reported as abuse in a timely manner. Additionally, an investigation result for resident #12 was submitted late. The incidents were substantiated as abuse but initially not recognized by the facility's IDT.

The facility failed to identify and report incidents of resident-to-resident abuse in a timely manner and did not submit investigation results within required timeframes. Corrective actions included staff education on abuse identification and reporting, and ongoing audits of resident progress notes.

The facility was found deficient in multiple areas including failure to provide required Medicare notices, inadequate grievance policies, failure to protect residents from abuse, inaccurate resident assessments, medication administration errors, incomplete discharge summaries, fall prevention program failures leading to immediate jeopardy, unnecessary medication use, lack of dental services, insufficient dietary manager qualifications, food safety violations, inadequate infection preventionist qualifications, failure to ensure call lights were accessible, and ineffective infection control and antibiotic stewardship programs.

The facility was found to be sharing nursing staff between the nursing home and assisted living without proper scheduling or payroll coding, resulting in licensed nurses not always being present in the nursing home. This practice had the potential to affect residents needing assistance.

The facility was found deficient in multiple areas including failure to obtain proper consents for psychotropic medications, inconsistent code status documentation, inadequate restraint assessments, failure to complete significant change assessments, incomplete care plans, failure to provide ordered treatments, lack of restorative care programs, failure to monitor weight changes, improper respiratory equipment cleaning, inadequate nursing competencies, medication management issues including expired medications and lack of insulin parameters, food safety violations, infection control deficiencies, and failure to monitor antibiotic use.

The complaint investigation found that staff did not respond timely to the resident's elopement bracelet alarm, and the resident was found outside by hospital staff and taken to the emergency room. The fall was unwitnessed, and the resident was started on antibiotics for a urinary tract infection.

Facility staff failed to respond to a door alarm for resident #3 who exited the facility and fell in the parking lot. The resident was found by hospital staff and taken to the emergency room, diagnosed with a urinary tract infection but sustained no injuries from the fall. Staff training on door alarms occurred after the incident, and resident elopements were not included in the facility's QAPI program.