Inspection Reports for Northridge Health and Rehabilitation
100 MEDICAL CENTER DRIVE, COMMERCE, GA, 30529
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 6, 2025 found no deficiencies related to the investigated complaints, which were unsubstantiated. Earlier inspections showed a pattern of deficiencies primarily involving resident care, such as inadequate Activities of Daily Living (ADL) assistance including nail care, and environmental issues like maintenance of bathroom exhaust fans and air conditioning units. Life Safety Code surveys from prior years cited fire safety and smoke barrier maintenance issues, though these were addressed in subsequent revisits. Complaint investigations have frequently been unsubstantiated, with some substantiated complaints not resulting in regulatory violations. The facility appears to have corrected previously cited deficiencies over time, indicating improvement in compliance with care and safety standards.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
84 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: May 6, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00253020 and GA00254728.
Complaint Details
Complaints GA00253020 and GA00254728 were investigated and found to be unsubstantiated.
Findings
The complaints GA00253020 and GA00254728 were unsubstantiated, and no deficiencies were cited related to these complaints.
Report Facts
Complaints investigated: 2
Facility census: 84
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00251177, GA00245689, GA00249400, and GA00251151.
Complaint Details
Complaints GA00251177 and GA00251151 were substantiated. Complaints GA00249400 and GA00245689 were unsubstantiated.
Findings
Complaints GA00251177 and GA00251151 were substantiated, while complaints GA00249400 and GA00245689 were unsubstantiated. No regulatory violations were cited during the survey.
Report Facts
Complaints investigated: 4
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
A Life Safety Code (LSC) revisit was conducted as a desk review to verify correction of previously cited deficiencies.
Findings
The revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on February 29, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification and Complaint survey that concluded on February 29, 2024.
Findings
All deficiencies cited as a result of the Recertification in conjunction with a Complaint survey were found to be corrected.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: Feb 29, 2024
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failure to provide nail care for two residents (R27 and R41), resulting in long, broken, and jagged fingernails.
Failure to provide a safe, clean, comfortable, and homelike environment in five rooms due to dirty bathroom ceiling exhaust fan vent covers and a dirty, damaged PTAC unit.
Report Facts
Facility census: 82
Sampled residents: 45
Rooms with environmental deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant (CNA) | Interviewed regarding nail care for residents R27 and R41 |
| Director of Nursing (DON) | Interviewed regarding expectations for nail care and staff responsibilities | |
| Assistant Maintenance Director (AMD) | Interviewed regarding environmental sanitation deficiencies | |
| Maintenance Director (MD) | Interviewed regarding cleaning policies and maintenance of facility | |
| Administrator | Interviewed regarding facility policies and maintenance issues |
Inspection Report
Routine
Census: 82
Deficiencies: 3
Date: Feb 29, 2024
Visit Reason
A standard survey was conducted from 2/27/2024 through 2/29/2024, including investigation of Complaint Intake Number GA00243980, which was found unsubstantiated.
Complaint Details
Complaint Intake Number GA00243980 was investigated in conjunction with the standard survey and was found unsubstantiated.
Findings
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).
Deficiencies (3)
Facility failed to provide a safe/clean/comfortable/homelike environment for five rooms due to dirty bathroom ceiling exhaust fan vent covers and a dirty, damaged PTAC unit.
Facility failed to follow the care plan for two residents by not assisting with Activities of Daily Living, specifically failing to provide nail care resulting in long, broken, and jagged fingernails.
Facility failed to provide ADL care for dependent residents, specifically nail care for two residents, potentially affecting comfort, body image, and infection risk.
Report Facts
Facility census: 82
Sampled residents: 45
Residents with care plan deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant AA | Certified Nursing Assistant | Interviewed regarding residents' nail care and care refusals. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for nail care and staff responsibilities. |
| Assistant Maintenance Director | Assistant Maintenance Director | Confirmed dirty exhaust fan vent covers and damaged PTAC unit; stated housekeeping responsibilities. |
| Maintenance Director | Maintenance Director | Provided information on cleaning logbook and maintenance policies. |
| Administrator | Administrator | Confirmed lack of maintenance policy and requested immediate correction of damaged items. |
Inspection Report
Life Safety
Census: 83
Capacity: 86
Deficiencies: 5
Date: Feb 28, 2024
Visit Reason
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.
Findings
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.
Deficiencies (5)
Stairwell door on C Hall near elevator failed to latch due to removed latching device.
Occupant notification of the fire alarm system not provided throughout all occupied areas, including the enclosed courtyard.
Fire alarm system indicated a trouble signal identified as a ground fault.
Sprinkler system maintenance deficiencies including obstructed access to riser, inadequate supply of spare sprinkler heads, and inaccurate list of spare sprinkler heads needed.
Penetrations in smoke barrier and fire rated walls on C Hall and Willowbrook Hall not properly maintained.
Report Facts
Census: 83
Total Capacity: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00227967, #GA00234117, #GA00229058, and #GA00228335 were unsubstantiated. Complaints #GA00239920 and #GA00226191 were substantiated.
Findings
Complaints #GA00227967, #GA00234117, #GA00229058, and #GA00228335 were found to be unsubstantiated, while complaints #GA00239920 and #GA00226191 were substantiated. No regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Northridge Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided page; only initial comments are noted without further elaboration.
Inspection Report
Re-Inspection
Census: 100
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
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.
Findings
All deficiencies cited as a result of the prior Recertification/Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Date: Jul 6, 2022
Visit Reason
A complaint survey was conducted to investigate Complaint Number GA00223523 at Northridge Health and Rehabilitation from July 5, 2022 through July 7, 2022.
Complaint Details
Complaint Number GA00223523 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the investigation.
Report Facts
Resident census: 100
Inspection Report
Renewal
Deficiencies: 3
Date: Apr 8, 2022
Visit Reason
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.
Findings
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.
Deficiencies (3)
Failure to implement fall prevention care plans for residents R#48 and R#74, including missing fall mats, anti-tip bars on wheelchairs, and non-skid strips.
Failure to develop a care plan addressing vision impairment for resident R#41.
Failure to provide adequate ADL care related to nail care and shaving for residents R#55, R#73, and R#91, with observations of unshaved facial hair and long nails with debris.
Report Facts
Residents reviewed for care plan implementation: 25
Residents reviewed for ADL care: 4
Personal hygiene care days: 6
Personal hygiene care days: 10
Personal hygiene care days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA TT | Certified Nursing Assistant | Interviewed regarding fall prevention interventions for resident R#48 and R#74 |
| CNA VV | Certified Nursing Assistant | Interviewed regarding fall prevention interventions for residents R#48 and R#74 |
| MDS Nurse UU | MDS Nurse | Interviewed regarding care plan transmission and vision care plan for resident R#41 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall prevention care plans and ADL care expectations |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding care plan information transmission and staff huddle meetings |
| CNA AA | Certified Nursing Assistant | Interviewed regarding shaving and nail care responsibilities |
| Nursing Assistant BB | Nursing Assistant | Interviewed regarding shaving and nail care responsibilities |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Interviewed regarding shaving and nail care responsibilities |
| CNA KK | Certified Nursing Assistant | Interviewed regarding shaving and nail care duties and documentation practices |
| Administrator | Administrator | Interviewed regarding staff responsibilities for shaving and nail care |
| LPN XX | Licensed Practical Nurse | Interviewed regarding staff education on fall prevention interventions |
Inspection Report
Routine
Census: 110
Deficiencies: 9
Date: Apr 8, 2022
Visit Reason
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.
Complaint Details
Complaint Numbers GA000221419 and GA000220768 were investigated in conjunction with the standard survey.
Findings
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.
Deficiencies (9)
Failure to treat residents with dignity by serving meals on disposable dinnerware without proper resident approval.
Failure to implement and revise comprehensive care plans to prevent falls and address vision impairment for residents.
Failure to provide adequate ADL care including shaving and nail care for residents.
Failure to maintain proper body alignment for a resident in a geriatric chair.
Failure to ensure adequate supervision and interventions to prevent falls for residents.
Failure to employ sufficient dietary staff to safely and effectively carry out food and nutrition service functions.
Failure to serve food at palatable and safe temperatures and failure to maintain proper food handling and hygiene practices in the kitchen.
Failure to ensure staff wore masks properly covering nose and mouth.
Failure to implement antibiotic stewardship program protocols to monitor and assess antibiotic use.
Report Facts
Resident census: 110
Residents affected by disposable dinnerware: 106
Temperature of soup at plating: 158.5
Temperature of soup at service: 120
Temperature of fried chicken at plating: 178
Temperature of fried chicken at service: 133
Temperature of cheesecake at plating: 37
Temperature of cheesecake at service: 54.5
Hand washing duration: 7
Hand washing duration: 9
Hand washing duration: 11
Temperature of resident R#101: 99.1
Antibiotic dose: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Certified Dietary Manager | Named in findings related to disposable dinnerware use and food temperature observations |
| JJ | Cook | Named in findings related to disposable dinnerware use and food temperature observations |
| KK | Certified Nursing Assistant | Named in findings related to shaving and nail care deficiencies |
| AA | Certified Nursing Assistant | Named in findings related to shaving and nail care deficiencies |
| TT | Certified Nursing Assistant | Named in findings related to fall prevention interventions |
| VV | Certified Nursing Assistant | Named in findings related to fall prevention interventions |
| UU | MDS Nurse | Named in findings related to fall prevention and care plan revisions |
| DD | Licensed Practical Nurse | Named in findings related to improper mask use |
| RR | Registered Nurse | Named in findings related to improper mask use |
| Environmental Services | Named in findings related to improper mask use and food handling | |
| LL | Regional Nurse | Named in interview regarding handwashing training |
| WW | Assistant Director of Nursing | Named in interview regarding handwashing training |
Inspection Report
Life Safety
Census: 108
Capacity: 167
Deficiencies: 0
Date: Apr 8, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
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.
Report Facts
Stories: 2
Construction Type: 2
Year Constructed: 1976
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints #GA00218474 and #GA00218605.
Complaint Details
Complaint #GA00218474 was unsubstantiated with no regulatory violations cited. Complaint #GA00218605 was substantiated with no regulatory violations cited.
Findings
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.
Report Facts
Facility census: 111
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against Northridge Health and Rehabilitation.
Complaint Details
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.
Findings
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.
Inspection Report
Abbreviated Survey
Census: 119
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211148.
Complaint Details
Complaint #GA00211148 was substantiated with no regulatory violations cited.
Findings
The complaint #GA00211148 was substantiated, but no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints (#GA00198936, #GA00199334, #GA00203783, #GA00206112, #GA00207281, #GA00209166, and #GA00210284).
Complaint Details
Complaints #GA00198936, #GA00199334, #GA00203783, #GA00206112, #GA00207281, #GA00209166, and #GA00210284 were investigated and found to be unsubstantiated.
Findings
All complaints investigated during the survey were found to be unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00197244, #GA00199210, #GA00197265, and #GA00197564.
Complaint Details
Investigation of four complaints: #GA00197244 and #GA00197265 were unsubstantiated; #GA00199210 and #GA00197564 were substantiated with no regulatory violations.
Findings
Complaints #GA00197244 and #GA00197265 were unsubstantiated. Complaints #GA00199210 and #GA00197564 were substantiated but with no regulatory violations.
Inspection Report
Routine
Census: 103
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
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.
Findings
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.
Inspection Report
Routine
Census: 105
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
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.
Findings
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.
Inspection Report
Abbreviated Survey
Census: 156
Deficiencies: 0
Date: Jun 4, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegations GA#00196856 and GA#00196794.
Complaint Details
The survey was complaint-related, investigating two allegations (GA#00196856 and GA#00196794), both unsubstantiated.
Findings
Both allegations investigated during the survey were found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 149
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/10/2019 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected at the time of the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 10, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to ensure professional standards of care for urinary catheter insertion for resident #121, including multiple unsuccessful attempts and inappropriate nurse responses.
Forceful digital dis-impaction of resident #55 without physician order, ignoring resident's request for a break.
Failure to conduct a full investigation of alleged abuse incidents involving residents #121 and #55.
Report Facts
Number of residents sampled: 57
Number of catheterized residents assessed: 5
Licensed nurses educated: 34
LPNs educated: 24
RNs educated: 10
Attempts to insert catheter: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN II | Licensed Practical Nurse | Nurse involved in multiple failed catheter insertion attempts and forceful digital dis-impaction; suspended and terminated |
| LPN EE | Licensed Practical Nurse | Conducted orientation and competency check-off for LPN II; interviewed regarding incidents |
| CNA FF | Certified Nursing Assistant | Witnessed catheter insertion attempts and reported concerns |
| CNA GG | Certified Nursing Assistant | Witnessed forceful digital dis-impaction and reported concerns |
| CNA HH | Certified Nursing Assistant | Witnessed catheter insertion attempts and reported concerns |
| Administrator | Facility Administrator | Informed of immediate jeopardy and involved in termination of LPN II |
| Director of Nursing | Director of Nursing | Informed of immediate jeopardy, conducted patient assessments, and involved in staff education |
| Medical Director | Medical Director | Interviewed regarding catheter insertion and dis-impaction procedures |
Inspection Report
Recertification
Census: 151
Deficiencies: 6
Date: Jan 10, 2019
Visit Reason
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.
Complaint Details
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).
Findings
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.
Deficiencies (6)
Failure to protect Resident #121 from abuse related to multiple failed urinary catheter insertion attempts with verbal threats and lack of full investigation.
Failure to protect Resident #55 from abuse related to forceful digital dis-impaction without physician order and refusal to stop when resident requested a break.
Failure to develop and implement abuse/neglect policies and procedures including investigation and prevention.
Failure to thoroughly investigate abuse allegations and prevent further abuse during investigation.
Failure to provide services meeting professional standards of care related to urinary catheter insertion and treatment of constipation.
Failure of administration to ensure effective and efficient use of resources to maintain highest practicable well-being of residents, including failure to conduct thorough investigations and oversight.
Report Facts
Resident census: 151
Number of catheter insertion attempts: 9
Number of residents interviewed: 78
Number of residents assessed: 73
Number of licensed nurses educated: 34
Number of licensed nurses: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN II) | Named as alleged perpetrator in abuse incidents involving Residents #121 and #55; continued to work until dismissal on 2019-01-09. | |
| Director of Nursing (DON) | Informed of abuse allegations; conducted incomplete investigation; failed to report and prevent further abuse. | |
| Administrator | Informed of abuse allegations; failed to ensure thorough investigation and oversight. | |
| Licensed Practical Nurse (LPN EE) | Inserted catheter successfully after LPN II failed; reported abuse incident involving Resident #55. | |
| Certified Nursing Assistants (CNAs) FF, GG, HH | Witnesses to abuse incident involving Resident #121; provided statements. | |
| Regional Vice President | Provided education to Administrator and DON on roles, responsibilities, and abuse policies. |
Inspection Report
Life Safety
Census: 156
Capacity: 167
Deficiencies: 5
Date: Jan 8, 2019
Visit Reason
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.
Findings
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.
Deficiencies (5)
Incomplete fire sprinkler coverage in unit A, E, and D stairwells.
Missing information data plate on the fire sprinkler riser.
Fire extinguishers installed at 72 inches height instead of required 60 inches.
Fire rated walls in basement storage room and B-Hall have unsealed penetrations.
Clean utility room on basement floor lacks proper oxygen storage signage.
Report Facts
Residents at risk due to incomplete sprinkler coverage: 35
Residents at risk due to missing sprinkler riser data plate: 10
Residents at risk due to fire extinguisher height: 15
Residents at risk due to unsealed fire rated wall penetrations: 20
Residents at risk due to lack of oxygen storage signage: 10
Census: 156
Total capacity: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2018
Visit Reason
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.
Complaint Details
Complaint #GA00192047 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00191906 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00191906 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
An unannounced complaint investigation was conducted based on complaints GA00191625 and GA00191785.
Complaint Details
The investigation was unannounced and based on two complaint numbers GA00191625 and GA00191785. No deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation.
Inspection Report
Abbreviated Survey
Census: 160
Deficiencies: 0
Date: Sep 12, 2018
Visit Reason
An Abbreviated Survey was conducted to investigate complaints GA00189653 and GA00189444.
Complaint Details
Complaint GA00189653 was substantiated with no deficiencies; complaint GA00189444 was unsubstantiated.
Findings
Complaint GA00189653 was substantiated with no deficiencies found, and complaint GA00189444 was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186984 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186984 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 22, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Routine
Census: 161
Deficiencies: 0
Date: Feb 2, 2018
Visit Reason
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.
Findings
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.
Inspection Report
Life Safety
Census: 161
Capacity: 167
Deficiencies: 5
Date: Jan 30, 2018
Visit Reason
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.
Findings
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.
Deficiencies (5)
Facility failed to keep corridors free of obstructions such as wheelchairs and chairs, risking 161 residents in case of fire.
Interior and exterior stairs did not comply with 4 inch vertical spacing on railings, risking 161 residents.
Facility failed to provide emergency lighting for ground floor exterior exit for maintenance and stair ground floor exit, risking 10 residents and staff.
Penetrations through maintenance/mechanical room were not sealed, risking 5 residents.
Fire extinguisher in A-Hall basement elevator room was not mounted properly, risking maintenance staff.
Report Facts
Census: 161
Total Capacity: 167
Residents at risk due to corridor obstruction: 161
Residents at risk due to stair railing non-compliance: 161
Residents and staff at risk due to lack of emergency lighting: 10
Residents at risk due to unsealed penetrations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 20, 2017
Visit Reason
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.
Complaint Details
Complaint investigation for complaints #GA00174996; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey conducted from 6/19/17 through 6/20/17.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
An abbreviated survey was conducted from March 10, 2017 through March 14, 2017 to investigate complaints GA00171242, GA00171909, and GA00167934.
Complaint Details
The complaints investigated were GA00171242, GA00171909, and GA00167934; none were substantiated.
Findings
The complaints were not substantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
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.
Findings
It was determined that all deficiencies cited during the prior surveys had been corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Northridge Health and Rehabilitation following a survey completed on March 3, 2017.
Findings
The document contains no detailed deficiencies or findings; it only includes an initial comments section without specific content.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 23, 2017
Visit Reason
A Follow-Up Survey was conducted to determine if deficiencies cited during the previous Follow-Up Survey on 2017-01-27 had been corrected.
Findings
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.
Deficiencies (1)
NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction requirement not met.
Inspection Report
Follow-Up
Capacity: 156
Deficiencies: 1
Date: Jan 27, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Facility failed to properly maintain rated smoke barrier walls with holes and unprotected penetrations above ceilings near corridor doors, Administrator Office, Room 264, and corridors at rooms 265, 266, 416, and 417.
Report Facts
Total residents at risk: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings during the follow-up tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 27, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 157
Capacity: 167
Deficiencies: 1
Date: Dec 15, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
The arm of the self-closing device was missing on the smoke barrier door to resident room 264 located on the D/E wing.
Report Facts
Census: 157
Total Capacity: 167
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