North Point Village, Assisted Living & Memory Care

The licensee failed to conduct two-step tuberculosis testing for one staff member.

Wall penetration in room 213; facility unable to provide documentation for annual fire wall inspection.

Missing documentation for monthly load tests and weekly inspections for the backup generator.

Missing electrical face plates in 2nd floor tool room and 1st floor medical room behind refrigerator.

Manual pull stations blocked by furniture in dining room, Cottage-A, and Cottage-C.

Combustible storage found in 1st floor mechanical/electrical room next to receiving.

Missing quarterly sprinkler reports, missing 5-year testing documentation, particulate/paint on sprinklers, unreadable PIV, and expired fire extinguisher service.

Storage found too close to the sprinkler in room 413.

2nd floor laundry door did not latch; 1st floor medical room door propped open.

Improper use of power strips/multiplug adapters in room 414, 2nd floor activities room, and 2nd floor activities office.

Multiple penetrations in ceilings/doors (basement mechanical room, C-cottage, 3rd floor kitchen, laundry room).

Facility unable to provide documentation for required smoke detector sensitivity testing.

Failed to follow fall program policy and procedures for six residents sampled for falls; falls were not tracked to decrease risk.

Failed to monitor the need for as needed medications for bowel movements for one resident.

Failed to provide safe intermittent nursing service practices for three residents; delegated tasks performed without RN oversight.

Failed to ensure residents received medications as prescribed and failed to follow provider orders for blood pressure medications and antibiotics.

Facility failed to monitor the need for as-needed medications for bowel movements for 1 of 7 residents.

Some staff were missing required certifications; one medication technician was missing CPR training.

Facility failed to ensure Negotiated Service Plans were signed by the resident, representative, or facility representative for 4 of 13 residents.

Facility failed to follow policies and procedures related to fall management for 4 of 5 residents, resulting in un-tracked falls and a lack of interventions.

Facility failed to ensure residents received medications as prescribed, resulting in missed doses for multiple residents and inability to determine reasons for missed doses.

Facility failed to ensure residents received medications as prescribed for 2 of 7 residents and failed to follow physician orders for blood pressure monitoring for 1 of 1 resident. Resulted in delayed administration and failure to complete antibiotic courses.

Facility failed to investigate all falls for sampled residents and had inconsistent responses regarding falls.

Facility failed to follow policy regarding weekly review and documentation for residents with more than two falls in a 30-day period.

Failed to complete a full assessment within 14 days of admission for 2 of 2 residents reviewed.

Facility failed to complete an annual self-medication assessment for 1 of 1 residents sampled (Resident 1).

Facility failed to develop a plan with interventions to monitor weight loss and nutritional deficiency for 1 of 1 resident (Resident 4) at risk for weight loss.

Facility failed to follow fall program policy/procedures for 6 of 6 sampled residents. Falls were not tracked in the Weekly at Risk Meeting, increasing risk of harm.

Facility failed to investigate all falls for sampled residents.

Failed to ensure a safe medication system; medications were not given as prescribed for 5 of 12 residents, including missed doses, undocumented refusals, and failure to follow physician parameters for blood pressure and blood sugar.

Facility failed to reevaluate need for electronic monitoring, obtain dated signatures from residents, document in service agreements, and obtain court orders for audio monitoring for residents 7 and 13.

Facility failed to ensure required orientation, safety, basic, specialty, CPR, and first aid training/certifications were completed for several staff members.

The facility was unable to locate the orientation checklist for one Medication Aide and unable to locate three weeks of staff schedules showing actual work hours.

Facility failed to document bowel movement monitoring for Resident 3; failed to provide safe delegated nursing practices for Residents 2, 13, and 15 (missing re-evaluations, missing delegation assessments).

Failed to investigate, document findings, and determine circumstances of falls for 3 of 5 residents reviewed.

Facility failed to monitor changing physical health conditions for 1 of 9 residents (Resident 3) regarding bowel movements and 'as needed' medications.

Facility failed to ensure TB screening was completed within three days of hire for 3 of 6 staff members sampled.

Facility failed to obtain necessary consents and conduct required assessments/supervision for nurse delegation regarding insulin administration for 1 of 1 residents sampled.

Facility failed to ensure staff evaluated and took appropriate action for wounds sustained by a resident, leading to pain and risk of ongoing skin breakdown.

Facility failed to provide care in a manner that promoted resident health and well-being, resulting in pain, discomfort, lack of wound assessment/treatment, infection, and need for surgical intervention.

Failed to provide care in a manner which promoted health and well-being for one resident, resulting in pain, discomfort, lack of wound assessment/treatment, infection, and risk of health complications.

Failed to ensure staff evaluated and took appropriate action for wounds sustained by one resident, resulting in lack of assessment/treatment and risk of ongoing skin breakdown.

Facility failed to provide appropriate personal protective equipment (gloves) to 3 of 5 staff observed providing resident care. Staff reported the facility had run out of gloves multiple times.