Center at Northridge, LLC, the

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Sta.. Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3 1. Fire Doors to patient room.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:IT room needs fire caulk aro.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. Delayed Egress doors state delayed .. Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Records were unavailable at the time of the survey to document t.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following: 1 The cylinder needs to be labeled/separated.. Based on observation, the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Semi-Annual Hood Inspection | No report available2. Semi-Annual Hood Inspection | No report available3. The kitche.. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continui.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Only 2 fire drills were conducted throughout the last twelve months.NFPA 101, 19.7.1.6.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducte.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Escutcheon plates through the building exceed .. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. And 7.9 This was evidenced by:There were no exit sign testing.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1) power strip supplying po..

A recertification survey with complaint #CO35008, #CO35377 and #CO35389 was completed on 3/27/24-4/2/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 3/27/24 to 4/2/24. No deficiencies were cited. Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process focussing on the resident' s discharge goals for three (#76, #47 and #64) of five residents reviewed for discharge planning out of 38 sample residents. Specifically, the facility failed to for Resident #76, Resident #47 and Resident #64:-Involve the resident and the resident' s representative in the discharge plan; and, -Develop discharge care plan with appropriate goals and approaches.Findings include:I. Facility policy and procedureThe Admission, Discharge and Transfer policy, revised 2/9/23, was provided by the nursing home administrator (NHA) on 4/2/24 at 12:31 p.m. It read in pertinent part:"Regardless of payment method, all residents have access to: Care that is timely and meets the needs of the resident; access to their physician; Staff, including administrative staff; and Care-planning and discharge-planning processes. Staff involved in the move in, transfer and move out process will ensure that the focus.. Based on record review and interviews, the facility failed to ensure the safety and supervision to prevent accidents for one (#66) of three residents reviewed for falls of 38 sample residents. Specifically, the facility failed to ensure Resident #66 was safe while ambulating with therapy. Findings include:I. Facility policy and procedureThe Fall Prevention policy, revised October 2017, was received from the nursing home administrator (NHA) on 4/2/24 at 12:31 p.m. The policy documented in pertinent part, "The post fall procedure includes nursing to assess the patient and determine the most appropriate course of action. Notification of the following must take place: physician, responsible party, and director of nursing (DON). Risk management was to be completed. Determine what interventions needed to be implemented to prevent further falls, and complete orders and/or tasks for fall prevention and for further skin injuries if indicated."II. Resident #66 statusResident #66, age under 65, was admitted on 2/23/24. According to the A..