Inspection Reports for Northridge Health and Rehabilitation

An abbreviated/partial extended survey was conducted to investigate complaints GA00253020 and GA00254728.

The complaints GA00253020 and GA00254728 were unsubstantiated, and no deficiencies were cited related to these complaints.

Complaints GA00253020 and GA00254728 were investigated and found to be unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00251177, GA00245689, GA00249400, and GA00251151.

Complaints GA00251177 and GA00251151 were substantiated, while complaints GA00249400 and GA00245689 were unsubstantiated. No regulatory violations were cited during the survey.

Complaints GA00251177 and GA00251151 were substantiated. Complaints GA00249400 and GA00245689 were unsubstantiated.

A Life Safety Code (LSC) revisit was conducted as a desk review to verify correction of previously cited deficiencies.

The revisit found that all previously cited Life Safety Code deficiencies had been corrected.

A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on February 29, 2024.

All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.

A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification and Complaint survey that concluded on February 29, 2024.

All deficiencies cited as a result of the Recertification in conjunction with a Complaint survey were found to be corrected.

The inspection was conducted as a State Licensure survey at Northridge Health and Rehabilitation from February 27, 2024 through February 29, 2024, to determine compliance with the State Long Term Care Requirements.

The facility failed to follow care plans for two residents by not providing adequate Activities of Daily Living (ADL) care, specifically nail care, resulting in long, broken, and jagged fingernails. Additionally, the facility failed to maintain a safe, clean, and comfortable environment in five rooms due to dirty bathroom ceiling exhaust fan vent covers and a damaged Packaged Terminal Air Conditioner (PTAC) unit.

A standard survey was conducted from 2/27/2024 through 2/29/2024, including investigation of Complaint Intake Number GA00243980, which was found unsubstantiated.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a safe, clean, and comfortable environment in five rooms due to dirty bathroom exhaust fan vent covers and damaged PTAC units, and failure to provide adequate Activities of Daily Living (ADL) care, specifically nail care, for two residents (R27 and R41).

Complaint Intake Number GA00243980 was investigated in conjunction with the standard survey and was found unsubstantiated.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with life safety requirements, including deficiencies in self-closing doors, fire alarm notification, fire alarm system maintenance, sprinkler system maintenance, and smoke barrier integrity. These issues potentially affect all residents.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.

Complaints #GA00227967, #GA00234117, #GA00229058, and #GA00228335 were found to be unsubstantiated, while complaints #GA00239920 and #GA00226191 were substantiated. No regulatory violations were cited.

Complaints #GA00227967, #GA00234117, #GA00229058, and #GA00228335 were unsubstantiated. Complaints #GA00239920 and #GA00226191 were substantiated.

The document is a statement of deficiencies and plan of correction for Northridge Health and Rehabilitation, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the provided page; only initial comments are noted without further elaboration.

A Revisit Survey was conducted from July 5, 2022 through July 7, 2022 at Northridge Health and Rehabilitation to verify correction of deficiencies cited in the Recertification/Complaint Survey concluded on April 8, 2022.

All deficiencies cited as a result of the prior Recertification/Complaint Survey were found to be corrected.

A complaint survey was conducted to investigate Complaint Number GA00223523 at Northridge Health and Rehabilitation from July 5, 2022 through July 7, 2022.

The complaint was unsubstantiated and no regulatory violations were cited during the investigation.

Complaint Number GA00223523 was investigated and found to be unsubstantiated with no regulatory violations cited.

The inspection was a licensure survey conducted from April 5, 2022 through April 8, 2022 to assess compliance with regulatory requirements for nursing care and facility operations.

The facility failed to implement care plans adequately to prevent falls for two residents, failed to develop a care plan for vision impairment for one resident, and failed to provide adequate ADL care related to nail care and shaving for three residents. Observations and interviews revealed missing fall prevention interventions and inconsistent hygiene care.

A standard survey was conducted by CertiSurv, LLC on behalf of the Georgia Department of Community Health from April 5, 2022 through April 8, 2022, including investigation of two complaints.

The facility was found not in substantial compliance with Medicare/Medicaid regulations. Deficiencies included failure to treat residents with dignity related to use of disposable dinnerware, failure to implement comprehensive care plans for fall prevention and vision impairment, inadequate ADL care including shaving and nail care, improper positioning of a resident in a geriatric chair, inadequate fall prevention interventions, insufficient dietary staffing leading to use of disposable dinnerware, failure to serve food at proper temperatures, improper food handling and hygiene practices in the kitchen, failure to wear masks properly by staff, and failure to implement antibiotic stewardship protocols.

Complaint Numbers GA000221419 and GA000220768 were investigated in conjunction with the standard survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the requirements of 42 CFR 483.73.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints #GA00218474 and #GA00218605.

Complaint #GA00218474 was unsubstantiated with no regulatory violations cited. Complaint #GA00218605 was substantiated with no regulatory violations cited. The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices for COVID-19 preparedness.

Complaint #GA00218474 was unsubstantiated with no regulatory violations cited. Complaint #GA00218605 was substantiated with no regulatory violations cited.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against Northridge Health and Rehabilitation.

Several complaints were investigated; six complaints were unsubstantiated with no regulatory violations cited, while three complaints were substantiated but also had no regulatory violations cited.

Complaints #GA00215465, #GA00215042, #GA00214191, #GA00214099, #GA00213711, and #GA00213683 were unsubstantiated. Complaints #GA00217163, #GA00216298, and #GA00214109 were substantiated. No regulatory violations were cited for any complaints.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00211148.

The complaint #GA00211148 was substantiated, but no regulatory violations were cited during the survey.

Complaint #GA00211148 was substantiated with no regulatory violations cited.

An abbreviated/partial extended survey was conducted to investigate multiple complaints (#GA00198936, #GA00199334, #GA00203783, #GA00206112, #GA00207281, #GA00209166, and #GA00210284).

All complaints investigated during the survey were found to be unsubstantiated and no regulatory violations were cited.

Complaints #GA00198936, #GA00199334, #GA00203783, #GA00206112, #GA00207281, #GA00209166, and #GA00210284 were investigated and found to be unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00197244, #GA00199210, #GA00197265, and #GA00197564.

Complaints #GA00197244 and #GA00197265 were unsubstantiated. Complaints #GA00199210 and #GA00197564 were substantiated but with no regulatory violations.

Investigation of four complaints: #GA00197244 and #GA00197265 were unsubstantiated; #GA00199210 and #GA00197564 were substantiated with no regulatory violations.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on July 30-31, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with federal infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.

An abbreviated/partial extended survey was conducted to investigate allegations GA#00196856 and GA#00196794.

Both allegations investigated during the survey were found to be unsubstantiated.

The survey was complaint-related, investigating two allegations (GA#00196856 and GA#00196794), both unsubstantiated.

A revisit survey was conducted to verify correction of deficiencies cited during the 1/10/2019 recertification survey.

All deficiencies cited in the prior recertification survey were found to be corrected.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected at the time of the follow-up survey.

The inspection was conducted due to complaints regarding failure to maintain professional standards of care related to urinary catheter insertion for resident #121 and treatment of constipation for resident #55.

The facility was found to have immediate jeopardy related to abuse and neglect involving improper catheter insertion attempts and forceful digital dis-impaction without physician orders. The nurse involved was suspended and later terminated. The facility implemented staff education, competency assessments, and systemic changes to address the deficiencies and remove the immediate jeopardy.

The complaint investigation substantiated immediate jeopardy due to abuse and neglect involving two residents. The facility failed to protect resident #121 from abuse during multiple catheter insertion attempts and resident #55 from forceful digital dis-impaction without orders. The nurse involved was suspended and terminated. The facility initiated an immediate investigation and reported the allegation of abuse to the state.

Recertification survey conducted from 2019-01-07 through 2019-01-10, including investigation of Complaint Intake Number GA00193144 related to abuse allegations and quality of care concerns.

The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to protect residents from abuse and neglect, failure to conduct thorough investigations of abuse allegations, failure to prevent further abuse, and failure to maintain professional standards of care. Immediate jeopardy was identified related to multiple failed urinary catheter insertion attempts with verbal threats to Resident #121 and forceful digital dis-impaction of Resident #55 without physician orders. The facility removed immediate jeopardy by suspending and terminating the involved nurse, conducting staff education, revising care plans, and implementing monitoring and quality assurance processes.

Complaint Intake Number GA00193144 triggered the investigation of abuse allegations involving Resident #121 and Resident #55. The complaint was substantiated with immediate jeopardy identified due to abuse and neglect by a Licensed Practical Nurse (LPN II).

A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.

The facility was found not in substantial compliance with fire safety requirements, including incomplete fire sprinkler coverage in stairwells, missing information data plate on the fire sprinkler riser, fire extinguishers installed too high, unsealed penetrations in fire rated walls, and lack of proper oxygen storage signage.

A complaint survey was conducted on 10/24-10/25/2018 to investigate complaint #GA00192047 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint investigation survey.

Complaint #GA00192047 was investigated and found to have no deficiencies.

A complaint survey was conducted to investigate complaint #GA00191906 to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00191906 was investigated and found to have no deficiencies.

An unannounced complaint investigation was conducted based on complaints GA00191625 and GA00191785.

No deficiencies were cited during the complaint investigation.

The investigation was unannounced and based on two complaint numbers GA00191625 and GA00191785. No deficiencies were found.

An Abbreviated Survey was conducted to investigate complaints GA00189653 and GA00189444.

Complaint GA00189653 was substantiated with no deficiencies found, and complaint GA00189444 was unsubstantiated.

Complaint GA00189653 was substantiated with no deficiencies; complaint GA00189444 was unsubstantiated.

A complaint survey was conducted to investigate complaint #GA00186984 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00186984 was investigated and found to have no deficiencies.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.

A standard survey was conducted at Northridge Health and Rehabilitation from January 29, 2018 through February 2, 2018 to assess compliance with Medicare/Medicaid regulations.

The facility was found to be in substantial compliance with the Health portion of Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with life safety requirements, including obstructed corridors, non-compliant stair railing spacing, lack of emergency lighting at certain exits, unsealed penetrations in the maintenance/mechanical room, and improperly mounted fire extinguishers.

The inspection was conducted to investigate complaints #GA00174996 at Northridge Health and Rehabilitation Center to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey conducted from 6/19/17 through 6/20/17.

Complaint investigation for complaints #GA00174996; no deficiencies were found.

An abbreviated survey was conducted from March 10, 2017 through March 14, 2017 to investigate complaints GA00171242, GA00171909, and GA00167934.

The complaints were not substantiated and no deficiencies were cited.

The complaints investigated were GA00171242, GA00171909, and GA00167934; none were substantiated.

The visit was a Health Revisit conducted to determine if deficiencies cited during the Standard Survey, an Abbreviated Survey of November 3, 2016, and the Federal Comparative Survey of December 16, 2016 had been corrected.

It was determined that all deficiencies cited during the prior surveys had been corrected.

This document is a Statement of Deficiencies and Plan of Correction for Northridge Health and Rehabilitation following a survey completed on March 3, 2017.

The document contains no detailed deficiencies or findings; it only includes an initial comments section without specific content.

A Follow-Up Survey was conducted to determine if deficiencies cited during the previous Follow-Up Survey on 2017-01-27 had been corrected.

It was determined that the deficiency cited during the previous Follow-Up Survey had been corrected. The report references a smoke barrier construction requirement that was not met previously but notes all previously cited survey tags have been corrected.

A Follow-Up Survey to the Life Safety Code Recertification Survey of 11/3/17 and to the Life Safety Code Comparative Federal Monitoring Survey of 12/15/16 was conducted to verify correction of previously cited deficiencies.

The facility failed to properly maintain rated smoke barrier walls, with holes and unprotected penetrations observed above ceilings in multiple locations, placing 156 residents at risk in the event of a fire.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited deficiencies had been corrected.

A Life Safety Code Comparative Federal Monitoring Survey was conducted following a state survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and related NFPA codes.

The facility was found not in substantial compliance due to failure to maintain smoke barrier doors. Specifically, the arm of the self-closing device was missing on a smoke barrier door to resident room 264.