Inspection Reports for
Northern Pines Rehabilitation and Nursing

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft: the facility failed to complete background checks on six employees prior to their start dates, including rehiring without a new background check.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report two allegations of abuse within the required two-hour timeframe and delayed reporting investigation findings for multiple residents.

F 0610 Respond appropriately to all alleged violations: the facility failed to fully investigate abuse allegations for five residents, with incomplete investigations lacking resident interviews and ongoing monitoring.

F 0610 Investigation of Alleged Abuse, Neglect, and Exploitation: the facility did not provide complete and thorough documentation of abuse investigations, including identifying and interviewing all involved persons.

F 0760 Ensure that residents are free from significant medication errors: the facility administered a controlled substance to one resident on three separate days without a current physician's order and failed to remove discontinued medication from the medication cart as required.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect residents from verbal and physical abuse by other residents for two of eighteen sampled residents, with incidents not initially identified as abuse by the interdisciplinary team.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: staff education was provided on identification and reporting of abuse after audits revealed missed abuse incidents, with ongoing monitoring implemented.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report allegations of abuse within 24 hours for two residents and failed to submit investigation results within five working days for one resident.

F0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to provide the required SNF ABN form to residents receiving Medicare Part A skilled services.

F0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to provide grievance forms accessible to all residents, allow anonymous filing, and include grievance official contact information in the policy.

F0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect residents from verbal and physical abuse by other residents and delayed identification and reporting of abuse incidents.

F0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report abuse allegations within required timeframes and delayed submission of investigation results.

F0641 Ensure each resident receives an accurate assessment: the facility failed to accurately code residents' medication use on MDS assessments, including antipsychotic and antibiotic medications.

F0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a resident's care plan to include anxiety management and related interventions.

F0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to prime insulin pens before administration, causing a resident to receive less insulin than prescribed.

F0661 Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge: the facility failed to complete a discharge summary including recapitulation of stay and post-discharge plan for a discharged resident.

F0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent immediate jeopardy level falls and injuries due to ineffective fall prevention programs, lack of root cause analysis, inadequate interventions, and inaccessible call lights for residents.

F0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: the facility failed to discontinue an antibiotic after a negative urine culture for a resident.

F0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to implement a gradual dose reduction for fluoxetine and failed to ensure adequate rationale and monitoring for psychotropic medication use in a resident with cardiovascular compromise.

F0790 Provide routine and 24-hour emergency dental care for each resident: the facility failed to provide dental services or offer dental care to residents with missing teeth or dentures.

F0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to ensure the dietary manager completed required certification training.

F0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: staff failed to wear hairnets properly in food service areas, risking contamination.

F0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently: the administrator failed to provide adequate oversight and training for the Administrator in Training and DON regarding fall prevention and performance improvement, failed to ensure a certified Infection Preventionist was employed, and failed to ensure a qualified Dietary Manager was employed.

F0880 Provide and implement an infection prevention and control program: the facility failed to offer hand hygiene to residents before meals and failed to perform hand hygiene between medication administrations.

F0881 Implement a program that monitors antibiotic use: the facility failed to maintain an effective antibiotic stewardship program including monitoring antibiotic use and following protocols for appropriate antibiotic prescribing.

F0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home: the facility failed to ensure the Infection Preventionist was certified prior to assuming the role.

F0919 Make sure that a working call system is available in each resident's bathroom and bathing area: the facility failed to ensure call lights were within reach for residents to call for assistance.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility shared nursing staff between the nursing home and assisted living without proper scheduling or coding, and nursing staff did not have separate time punches or pay codes for working in both areas.

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments: the facility failed to obtain verbal or written consent containing a complete explanation of risks versus benefits prior to giving psychotropic medication for one resident.

F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to have consistent code status information in the medical record for one resident.

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment: the facility failed to document ongoing re-evaluation of bolsters placed on a resident's bed to ensure they were not used as restraints.

F 0637 Assess the resident when there is a significant change in condition: the facility failed to complete a Significant Change assessment for a resident with severe unavoidable weight loss and medication discontinuation.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to complete person-centered, comprehensive care plans for two residents, omitting key focus areas such as COVID-19 risk, emotional needs, and nutrition preferences.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update a resident's care plan to reflect ongoing interventions for recurrent falls.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to provide ordered treatments and identify and document skin breakdown for a resident with multiple areas of skin breakdown, and failed to maintain adequate supplies of creams.

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to provide range of motion services to residents with contractures and decreased mobility and had no active restorative program.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to weigh a resident after illness and hospitalization, delaying identification of severe weight loss.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to clean nebulizer equipment properly, increasing risk for respiratory infections.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to ensure licensed nurses had necessary competencies and skill sets, as one nurse misdiagnosed a pressure ulcer and had incomplete skills training.

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to ensure adequate monitoring, glucose administration, and insulin parameters for a diabetic resident, with no documented interventions for low blood glucose readings.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to store medications in locked compartments for two residents and failed to remove expired medications and supplies from the medication room, supply closet, and medication cart.

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to have a certified person serving as the director of food and nutrition services, and staff were observed working without proper beard coverings.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to store, prepare, and serve food in accordance with professional standards, including improper food storage, expired items, and poor hygiene practices in the kitchen.

F 0880 Provide and implement an infection prevention and control program: the facility failed to review and update infection prevention policies annually, failed to ensure residents were offered hand hygiene before meals, and failed to perform hand hygiene when changing gloves during resident care.

F 0881 Implement a program that monitors antibiotic use: the facility failed to ensure the antibiotic stewardship program was followed with monitoring and tracking of antibiotic use for a resident treated for clostridium difficile infection.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: facility staff failed to respond timely to a door alarm for a resident elopement risk, resulting in the resident falling in the parking lot and requiring emergency room assessment.