Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
82% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulations, specifically focusing on meal service times and nutritional care.
Findings
The facility failed to serve meals in accordance with its policy and scheduled mealtimes, resulting in delayed breakfast service for two sampled residents. Observations and interviews confirmed that meals were served late, causing resident dissatisfaction and potential nutritional risk.
Deficiencies (1)
Failed to serve meals and snacks at times in accordance with resident’s needs, preferences, and requests, including providing suitable and nourishing alternative meals for residents who want to eat at non-traditional times or outside of scheduled meal times.
Report Facts
Facility census: 97
Meal service times: 8.5
Meal service times: 12.5
Meal service times: 17.5
Number of sampled residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | Certified Nursing Assistant | Interviewed regarding meal delivery process and late breakfast meals for residents |
| Dietary Manager | Dietary Manager | Interviewed about meal ordering process and new resident meal preferences |
| Administrator | Administrator | Interviewed about meal service expectations and timing |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to report and investigate allegations of verbal abuse, failure to revise care plans accurately, inadequate pressure ulcer care, unnecessary psychotropic medication administration, food safety violations, and failure to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices.
Complaint Details
The complaint investigation revealed failures in abuse reporting and investigation, care plan accuracy, pressure ulcer care, psychotropic medication administration, food safety, and infection control practices related to Enhanced Barrier Precautions.
Findings
The facility failed to timely report and investigate verbal abuse allegations for one resident, did not revise care plans accurately for two residents, failed to implement pressure ulcer treatment and prevention measures for one resident, administered unnecessary psychotropic medications to one resident, failed to maintain food safety standards in the kitchen, and did not implement required Enhanced Barrier Precautions for three residents with wounds or indwelling devices.
Deficiencies (7)
Failed to timely report an allegation of verbal abuse to the State Survey Agency for one resident.
Failed to thoroughly investigate an allegation of verbal abuse for one resident.
Failed to revise care plans accurately for two residents, including failure to identify inaccurate diagnosis and failure to address hospice services.
Failed to ensure pressure ulcer treatment orders and prevention measures were implemented for one resident.
Administered two separate doses of psychotropic medications without documented clinical need for one resident.
Failed to store foods in sealed containers, ensure cleanliness of the ice machine, and use adequate hand hygiene during food service.
Failed to implement Enhanced Barrier Precautions for three residents with chronic wounds or indwelling devices.
Report Facts
Residents reviewed for abuse: 25
Residents reviewed for care plan accuracy: 25
Residents reviewed for pressure ulcers: 25
Residents reviewed for psychotropic medication use: 25
Residents reviewed for Enhanced Barrier Precautions: 25
Resident R37 BIMS score: 15
Resident R345 BIMS score: 14
Resident R3 BIMS score: 15
Resident R10 BIMS score: 6
Open wound size on R3's left foot: 1.5
Open wound size on R3's left foot: 1
Psychotropic medication doses administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA7 | Certified Nursing Assistant | Named in verbal abuse allegation involving Resident R37 |
| FADON | Former Assistant Director of Nursing | Received verbal abuse report from Resident R37 and reported to Administrator |
| Director of Nursing | Director of Nursing | Provided statements on abuse reporting, care plan, wound care, and medication administration |
| LPN2 | Licensed Practical Nurse | Entered wound treatment order incorrectly and provided statements on wound care |
| Dietary Manager | Dietary Manager | Reported food safety violations and kitchen sanitation issues |
| Maintenance Director | Maintenance Director | Responsible for cleaning ice machine, confirmed cleaning but missed contamination on lid |
| Registered Nurse 2 | Registered Nurse | Provided statements on psychotropic medication administration and documentation |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Described catheter care procedures and PPE use |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | New employee trained on infection control, unaware of Enhanced Barrier Precautions |
| Assistant Director of Nursing 1 | Assistant Director of Nursing | Provided training and statements on infection control and Enhanced Barrier Precautions |
| Infection Preventionist/Wound Care Nurse | Infection Preventionist/Wound Care Nurse | Provided statements on wound care assessments and Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 28, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services. The survey was triggered by allegations of abuse, neglect, exploitation, or mistreatment.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate allegations of verbal abuse involving a resident. The facility also failed to take appropriate corrective actions to ensure resident safety.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. The facility failed to report allegations of verbal abuse timely and failed to thoroughly investigate allegations of abuse. Additional deficiencies were found related to care plan revisions, pressure ulcer treatment, psychotropic medication use, food safety, and infection control.
Deficiencies (7)
F609 Reporting of Alleged Violations: The facility failed to report an allegation of verbal abuse to the State Survey Agency for one resident within the required timeframe. This failure had the potential to affect resident safety.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate an allegation of verbal abuse for one resident. This failure had the potential to affect resident safety.
F657 Care Plan Timing and Revision: The facility failed to revise the care plan for two residents to address inaccurate medical diagnoses and hospice services. This could result in residents not receiving care to meet their specific needs.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure pressure ulcer treatment orders and prevention measures were implemented for one resident, leading to potential wound deterioration or development of avoidable pressure ulcers.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure a resident was free from unnecessary psychotropic medications, as two doses were given without documented clinical need.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store foods in sealed containers, ensure cleanliness of the ice machine, and maintain adequate hand hygiene during food service, risking foodborne illness to residents.
F880 Infection Prevention & Control: The facility failed to implement infection prevention and control measures, including enhanced barrier precautions for residents with multidrug-resistant organisms and proper wound care, increasing risk of infection spread.
Report Facts
Sample residents reviewed: 25
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 96
Residents affected: 3
Inspection Report
Life Safety
Census: 71
Capacity: 118
Deficiencies: 2
Date: Jun 25, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions on behalf of the State of Missouri to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found to be in noncompliance with NFPA 101 Life Safety Code requirements, including obscured exit signage and unsecured low voltage wiring. These deficiencies had the potential to affect all 71 residents present during the survey.
Deficiencies (2)
K293 Exit Signage: The facility failed to ensure the exit sign in the courtyard was visible and not obscured, violating NFPA 101 (2012 edition) 7.10.1.2.1. This issue affected 71 residents.
K511 Utilities - Gas and Electric: Low voltage wiring under seven feet for the fire alarm system dialer was not protected in interior walls or conduit, and a 4.5 inch electrical conduit was not secured within three feet of a box or panel, violating NFPA 70 National Electrical Code.
Report Facts
Residents affected: 71
Licensed beds: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed issues with exit signage and wiring | |
| Administrator | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure staff obtained physician's orders and assessed residents for safe administration of medications kept at the bedside for two sampled residents.
Complaint Details
The complaint investigation found that medications were left at bedside without physician's orders or assessments for self-administration, posing potential risk to residents. Staff interviews confirmed lack of policy and inconsistent medication administration practices.
Findings
The facility failed to have a policy on medication administration and did not ensure physician's orders or assessments for self-administration of medications were completed for residents with medications at bedside. Staff left medications at bedside without orders, and some residents had medications accessible without proper supervision or assessment.
Deficiencies (2)
Facility failed to ensure staff obtained physician's orders and assessed residents for safe administration of medication to be kept at the bedside for two sampled residents.
Facility provided no policy on medication administration.
Report Facts
Facility census: 96
Medication administration time: 7
Blood glucose reading: 153
Insulin units administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse A | Stated facility lacked medication at bedside and self-administration policies | |
| Licensed Practical Nurse A | LPN | Stated staff should not leave medication on residents bedside table |
| Registered Nurse A | RN | Administered medications to Residents #1 and #2, left medications at bedside for Resident #1 |
| Certified Medication Technician A | CMT | Reported finding medications at bedside without proper supervision |
| Licensed Practical Nurse B | LPN | Described standard medication administration practices |
| Administrator | Expected medications left at bedside to have physician's order | |
| Assistant Director of Nursing | ADON | Expected staff to watch residents take medications and not leave medications at bedside |
Inspection Report
Plan of Correction
Census: 96
Deficiencies: 2
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to assess compliance with medication administration regulations, specifically regarding resident self-administration of medications and related policies.
Findings
The facility failed to ensure staff obtained physician's orders and assessed residents for safe medication administration at the bedside for two sampled residents. The facility lacked a policy on medication administration and did not have a medications at bedside policy or self-administration of medications policy.
Deficiencies (2)
F554: The facility failed to ensure staff obtained physician's orders and assessed residents for safe administration of medication at the bedside for two sampled residents. The facility provided no policy on medication administration or self-administration of medications.
A4059: Self-administration of medication is permitted only if approved in writing by the resident's physician and in accordance with facility policy. This regulation was not met as evidenced by the facility's noncompliance with federal citation F554.
Report Facts
Facility census: 96
Date of survey: Nov 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration practices |
| Registered Nurse | Registered Nurse (RN) | Interviewed regarding medication administration practices |
| Certified Medication Technician | Certified Medication Technician (CMT) | Interviewed regarding medication administration practices |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration practices |
| Administrator | Administrator | Interviewed regarding medication policies and procedures |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication administration oversight |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as an annual survey of Northland Rehabilitation & Health Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness.
Findings
The facility was found to be in compliance with 43 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a survey completed on 02/22/2023 for Northland Rehabilitation & Health Care Center.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
A COVID-19 focused infection control and emergency survey was conducted to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
The document is an annual inspection report for Northland Rehabilitation & Health Care Center, summarizing the findings of the survey completed on 12/22/2022.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
The inspection was conducted as a licensure inspection and complaint investigation at Northland Rehabilitation & Health Care Center.
Complaint Details
No state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 2, 2022
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with federal regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 26, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 5
Date: Oct 6, 2021
Visit Reason
The visit was an abbreviated survey conducted to investigate deficiencies related to quality of care, free of accident hazards, and pain management following incidents involving resident falls and injuries.
Findings
The facility failed to thoroughly assess residents after falls, notify physicians promptly, ensure staff training on resident care needs, and provide adequate pain management. Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (5)
F684 Quality of Care: The facility failed to thoroughly assess two sampled residents after falls and failed to notify the residents' physicians promptly. Staff did not update care plans or document post-fall assessments adequately.
F689 Free of Accident Hazards: The facility failed to ensure all staff were trained and informed of residents' individual care needs, resulting in a resident sustaining a femur fracture during a transfer.
F697 Pain Management: The facility failed to assess, treat, and reassess two sampled residents for complaints of pain after falls, including failure to document pain assessments and follow-up effectiveness.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This was not met as evidenced by deficiencies F684, F689, and F697.
A4086 Doctor Notification-Change in Condition: Facility staff failed to notify the resident's physician in accordance with emergency treatment policies following significant changes in condition.
Report Facts
Facility census: 87
Deficiencies cited: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC guidelines.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness regulations.
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 4
Date: May 4, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to residents' rights and notice requirements before transfer or discharge at Northland Rehabilitation & Health Care Center.
Findings
The facility failed to protect the rights of a resident by allowing medical decisions to be made by a Durable Power of Attorney (DPOA) before the resident was declared incompetent. The facility also failed to provide a 30-day discharge notice including a safe discharge plan and appeal mechanism for a resident being discharged.
Deficiencies (4)
F551: The facility did not protect the rights of a resident by allowing the DPOA to make medical decisions before the resident was declared incompetent. The facility lacked a policy on declaring residents incompetent.
F623: The facility failed to provide a 30-day discharge notice including a safe discharge plan and appeal mechanism to a resident before discharge. The notice did not include all required information and was not timely provided.
A8015: The facility did not notify the resident, next of kin, or legally authorized representative at least 30 days in advance of transfer or discharge as required by regulation.
A8017: The facility failed to provide full and adequate notice of discharge rights and hearing opportunities to the resident in writing at least 30 days in advance, except in emergencies.
Report Facts
Facility census: 84
Deficiencies cited: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and an abbreviated survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness regulations.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from November 17 to December 3, 2020, to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Date: Nov 5, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding a mistaken emergency department transfer of a resident caused by incorrect room assignments in the electronic medical record.
Complaint Details
The complaint investigation substantiated that Resident #2 was mistakenly sent to the hospital emergency department due to incorrect room assignments. The facility failed to notify the resident representative promptly and lacked policies for such notifications. The investigation included interviews, record reviews, and documentation of the incident and follow-up actions.
Findings
The facility failed to immediately notify the resident representative about the mistaken emergency transfer and did not have policies regarding notifications. Two residents were affected by incorrect room assignments, resulting in one resident being sent to the hospital in error and the other wrongfully subjected to hospital testing. The facility did not provide treatment in accordance with professional standards and lacked documentation of transfers and returns from the emergency department.
Deficiencies (3)
F580 Notification of Changes: The facility failed to immediately notify the resident representative when Resident #2 was mistakenly sent to the hospital emergency department due to incorrect room assignments. The facility also lacked policies regarding notifications.
F684 Quality of Care: The facility failed to ensure two residents received treatment and care in accordance with professional standards, including incorrect hospital transfer and room assignments, lack of awareness by staff, and inadequate documentation of emergency department transfers.
A4087 Notify Responsible Party-Change in Condition: The facility did not meet the requirement to notify the responsible party of significant changes in the resident's condition as evidenced by failure to notify about the mistaken hospital transfer.
Report Facts
Facility census: 78
Audit frequency: 5
Audit duration: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from October 22 to October 27, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from May 20 through May 28, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 2
Date: Jan 14, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding comprehensive care plans and medication administration for residents.
Findings
The facility failed to meet professional standards in providing care and treatment, including failure to follow physicians' orders for intravenous therapy and failure to notify physicians of changes in resident conditions. Documentation and policy deficiencies were also noted.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to assure care and treatment met professional standards, including failure to follow physicians' orders for IV therapy and failure to notify physicians of resident condition changes.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies in care documented under F658.
Report Facts
Facility census: 65
Facility census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in relation to late entry and failure to administer IV fluids |
| Director of Nursing | Director of Nursing | Called IV department for assistance and provided statements regarding IV fluid administration |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding IV fluid administration and resident care |
| Nurse Practitioner A | Nurse Practitioner | Interviewed regarding resident treatment and medication administration |
| Registered Nurse A | Registered Nurse | Mentioned in medication administration report handoff |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 15
Date: Oct 17, 2019
Visit Reason
Annual inspection survey conducted at Northland Rehabilitation & Health Care Center to assess compliance with federal and state regulations.
Findings
The facility was found non-compliant with several requirements including posting of required information, advance directives documentation, transfer/discharge notices, comprehensive care plans, infection control, and medication administration. Deficiencies were cited across multiple areas affecting resident care and facility operations.
Deficiencies (15)
F575 Required Postings: The facility failed to post a list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups in a conspicuous location.
F578 Advance Directives: The facility failed to ensure staff obtained appropriate documentation and signatures related to residents' advance directives, affecting one of 19 sampled residents.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notice of transfer or discharge to residents or their responsible parties in a language they understood, affecting three of 19 sampled residents.
F656 Comprehensive Care Plan: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives for three sampled residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure residents received appropriate treatment and services to maintain continence and prevent infections, affecting two of 19 sampled residents.
F693 Tube Feeding Management/Restore Eating Skills: The facility failed to ensure residents fed by enteral means received appropriate treatment and documentation, affecting two residents.
F732 Nurse Staffing Information: The facility failed to post complete nurse staffing data in a prominent place accessible to residents and visitors on a daily basis.
F800 Provided Diet Meets Needs of Each Resident: The facility failed to provide residents with a nourishing, well-balanced diet meeting their nutritional and special dietary needs.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene and wound care, affecting four of 19 sampled residents.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4085 Infection Control/Communicable Disease: The facility shall use acceptable infection control procedures to prevent the spread of infection.
A4107 Clinical Records - Assessment/Interventions: Facilities shall ensure clinical records contain sufficient information reflecting assessments and interventions.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor: Each resident shall be served nutritious food properly prepared and seasoned, meeting nutritional needs based on medical condition and goals.
A8007 Resident Rights/Rules Posted, Alzheimer Unit Info: Resident rights and facility rules shall be posted in a conspicuous location and copies provided to anyone requesting them.
A8018 Emergency Discharges: The facility shall submit written notice of emergency discharge to the resident and next of kin or designee as soon as practicable.
Report Facts
Facility census: 76
Sampled residents: 19
Affected residents: 3
Affected residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madee Outz | Administrator | Signed plan of correction and involved in interviews |
| Director of Nurses | Interviewed regarding posting and care plan deficiencies | |
| Social Services Director | Interviewed regarding discharge notices | |
| Charge Nurses | Involved in verifying advance directive paperwork | |
| Registered Nurse (RN) A | Provided wound care and medication administration observations | |
| Certified Nurse Aide (CNA) C | Provided wound care and resident assistance | |
| Licensed Practical Nurse (LPN) A | Observed medication administration and resident care |
Inspection Report
Life Safety
Census: 76
Capacity: 90
Deficiencies: 3
Date: Oct 17, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain the required one-hour fire resistance rating of three of six smoke barrier walls and did not complete the annual inspection and testing of resident room electrical receptacles. These deficiencies had the potential to affect all residents.
Deficiencies (3)
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain the required one-hour fire resistance rating of three of six smoke barrier walls, including unsealed penetrations and gaps in smoke barriers.
K914 Electrical Systems - Maintenance and Testing: The facility failed to complete the annual inspection and testing of resident room electrical receptacles that were not listed as hospital grade, potentially affecting all residents.
A2054 Smoke Section Walls/Doors: Each smoke section must be separated by one-hour fire-rated walls and doors with at least a 20-minute fire rating or equivalent. This regulation was not met as evidenced by the K372 deficiency.
Report Facts
Census: 76
Total Capacity: 90
Inspection Report
Routine
Census: 76
Deficiencies: 10
Date: Oct 17, 2019
Visit Reason
The inspection was a routine survey of Northland Rehabilitation & Health Care Center to assess compliance with regulatory requirements related to resident rights, advance directives, transfer/discharge notifications, care planning, medication administration, nutrition, infection control, and staffing.
Findings
The facility was found deficient in multiple areas including failure to post ombudsman contact information conspicuously, incomplete documentation and verification of advance directives, failure to provide timely written transfer/discharge notices, incomplete and non-person-centered care plans, improper insulin administration and delayed meal service, inadequate catheter and peri care, incomplete documentation of enteral feeding and water intake, failure to post nurse staffing data accessibly, and failure to ensure hand hygiene and infection control protocols were followed.
Deficiencies (10)
Failed to post in a conspicuous location a list of names, addresses and telephone numbers of all pertinent State agencies and advocacy groups.
Failed to ensure staff obtained appropriate documentation and signatures related to residents' advance directives.
Failed to provide written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing, in a language they understood.
Failed to develop and implement comprehensive, person centered care plans that included measurable objectives to meet the residents' needs, conditions, and risks.
Failed to ensure staff followed professional standards of care when administering insulin and monitoring Low Air Loss mattress settings.
Failed to ensure staff provided complete peri care and catheter care in a manner to prevent infection or possibility of infection.
Failed to ensure staff documented enteral nutrition and water residents actually received and failed to follow facility guidelines related to enteral medication administration and feeding tube placement verification.
Failed to post the complete nurse staffing data in a prominent place readily accessible to all residents and visitors on a daily basis at the beginning of each shift.
Failed to provide residents with a nourishing, well-balanced diet, taking into consideration the preferences of each resident.
Failed to ensure staff followed hand washing/sanitizing protocols to prevent the spread of infection.
Report Facts
Residents affected: 11
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Provided wound care and discussed hand hygiene during wound treatment for Resident #52 |
| LPN C | Licensed Practical Nurse | Provided wound care and dressing changes for Resident #12 and Resident #36, with noted hand hygiene lapses |
| CNA E | Certified Nurse Aide | Provided peri and catheter care for Resident #31 and discussed proper peri care technique |
| CNA F | Certified Nurse Aide | Provided peri and catheter care for Resident #31 and discussed proper peri care technique |
| LPN A | Licensed Practical Nurse | Administered medications via feeding tube for Resident #213 and discussed feeding tube medication administration |
| CMT A | Certified Medication Technician | Administered medications to Resident #170 with noted hand hygiene lapses |
| Director of Nurses | Director of Nursing | Provided multiple interviews regarding care planning, insulin administration, hand hygiene, and staffing postings |
| Administrator | Facility Administrator | Provided interview regarding dietary services and meal delivery issues |
| Social Services Director | Social Services Director | Provided interview regarding transfer/discharge notices |
| MDS Coordinator | MDS Coordinator | Provided interview regarding care planning and Low Air Loss mattress monitoring |
| CNA A | Certified Nurse Aide | Provided interview regarding Resident #213 toileting assistance |
| CNA D | Certified Nurse Aide | Provided interview regarding Resident #52 repositioning and pressure ulcer care |
| Corporate Nurse | Corporate Nurse | Provided interview regarding transfer/discharge notices |
| Lead [NAME] | Lead Dietary Staff | Requested reprint of meal order tickets due to illegibility |
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 2
Date: Oct 3, 2019
Visit Reason
The inspection was conducted to investigate compliance with transfer and discharge requirements, specifically regarding the issuance of 30-day discharge notices and related documentation.
Findings
The facility failed to provide 30-day discharge notices for two sampled residents and did not issue required discharge notices with appeal information. The facility also lacked a policy on issuing discharge notices and had issues related to bed hold agreements and resident discharge planning.
Deficiencies (2)
F622 Transfer and Discharge Requirements: The facility failed to provide 30-day discharge notices for two sampled residents and did not issue discharge notices with required appeal information.
A8015 19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: No resident was transferred or discharged without proper 30-day notice to the resident, next of kin, attending physician, and responsible agency as required by regulation.
Report Facts
Facility census: 74
Discharge notices missing: 2
Bed hold fee: 250
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Apr 17, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding infection prevention and control practices at Northland Rehabilitation & Health Care Center.
Complaint Details
The complaint investigation found substantiated deficiencies related to infection control practices affecting one resident. The facility failed to follow proper infection prevention protocols during wound care.
Findings
The facility failed to ensure staff followed acceptable infection control procedures during a dressing change for one resident, resulting in potential risk of infection transmission. Multiple failures in hand hygiene, wound care, and sanitization of resident's bedside areas were observed.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to ensure staff followed infection control procedures during dressing changes, including hand hygiene, glove use, wound cleaning, and sanitizing resident's bedside areas. This affected one resident with a pressure ulcer and paralysis.
A4085 Infection Control/Communicable Disease: The facility did not meet regulations requiring acceptable infection control procedures and timely reporting of communicable diseases to the state division. Refer to F880 for details.
Report Facts
Facility census: 60
Days for reporting communicable disease: 7
Date of inspection: Apr 17, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed providing wound care and failing to follow infection control procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices and deficiencies |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 4
Date: Dec 14, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights and medication administration.
Findings
The facility failed to ensure residents' rights were respected, including timely response to call lights and removal of facial hair per resident preference. The facility also failed to provide a safe and effective medication administration system, resulting in significant medication errors for multiple residents.
Deficiencies (4)
F550 Resident Rights: The facility failed to assure staff treated three sampled residents with dignity, responding late to call lights and not removing facial hair per resident preference.
F760 Residents are Free of Significant Med Errors: The facility failed to provide a medication system free from significant errors for three of five sampled residents.
A4059 Medication Errors/Adverse Reactions Reported: The facility failed to report medication errors and adverse reactions immediately to the nursing supervisor and physician as required.
A8030 Dignity/Privacy: The facility failed to treat residents with full recognition of dignity and privacy in treatment and care.
Report Facts
Facility census: 47
Deficiencies cited: 4
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 7, 2018
Visit Reason
Annual licensure inspection of Northland Rehabilitation & Health Care Center was conducted to assess compliance with health facility regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 7, 2018
Visit Reason
Annual licensure inspection of Northland Rehabilitation & Health Care Center to assess compliance with regulatory requirements including emergency preparedness and life safety codes.
Findings
No deficiencies were cited in the emergency preparedness portion or the licensure inspection. The facility requires compliance with the 2012 Life Safety Code provisions.
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