The resident, identified as R190 in inspection records, told investigators repeatedly that they only had a urostomy — a bag to collect urine after bladder cancer surgery. But North Ridge Health and Rehab staff continued signing off on colostomy care every shift from December 2023 through July 2024.
"I don't have a colostomy," R190 told inspectors on July 10. "I use the toilet to have a bowel movement and have a bag to collect urine."
The error started with a nursing order entered incorrectly in December. Despite a double-check system meant to catch such mistakes, no one corrected it. Instead, nursing staff signed documentation confirming they had provided colostomy care that was medically impossible.
Registered nurse RN-A initially insisted R190 had both a colostomy and urostomy when reviewing the electronic records. Only after investigators informed the nurse that R190 said otherwise did RN-A investigate and discover the mistake.
"The order for colostomy care was a typo because R190 did not have a colostomy but did have a urostomy," RN-A told inspectors the next day. "The colostomy order should have been discontinued instead of documented on as completed."
Director of nursing acknowledged the facility had a double nurse sign-off process specifically designed to prevent such errors. She could not explain why staff continued falsely documenting colostomy care for seven months.
The documentation problems extended beyond impossible treatments. Federal inspectors found North Ridge Health failed to properly monitor three dialysis patients, missing critical post-treatment assessments that could detect life-threatening complications.
R45's case proved especially troubling. After the resident returned from a hospital stay where surgeons removed her dialysis access device due to infection, nursing staff continued documenting dialysis-related care that was no longer needed or possible.
Hospital discharge records from July 1 clearly stated R45's dialysis access had been surgically removed on June 25 and she no longer required dialysis. Yet staff documented checking for "thrill and bruit" — pulse and sound assessments of dialysis access sites — every shift through July 9.
Registered nurse RN-N admitted to documenting a bruit and thrill check on R45 on July 5, even after she told him the access device had been removed.
"I don't remember why I checked that off," he told investigators.
The facility also failed to complete a readmission assessment for R45 or update her care plan to reflect that dialysis was no longer needed. Orders for dialysis-related monitoring weren't discontinued until July 10 — nine days after her return from the hospital.
Missing post-dialysis assessments created additional safety risks. These evaluations check for dangerous complications like bleeding, infection, blood pressure changes, and fluid overload that can occur after dialysis treatments.
For R45, staff missed post-dialysis assessments on eight separate occasions between May 23 and June 15. When assessments were completed, they often lacked required information like current weight measurements.
R166 and R143, two other dialysis patients, experienced similar gaps in monitoring. R166's record showed missing post-dialysis assessments on five dates, while R143 lacked assessments on six occasions.
R143 told investigators during evening rounds that staff "never check me after dialysis."
The kidney unit manager confirmed that floor nurses were responsible for completing these assessments when residents returned from dialysis, but acknowledged the documentation failures.
Medication errors added another layer of risk. R40, a resident with severely impaired cognition, received blood pressure medication multiple times when their readings were too high for safe administration.
The resident was prescribed Midodrine, a medication that raises blood pressure, with specific parameters: give only when systolic pressure drops below 100 or diastolic below 60. But nursing records showed R40 received the medication on July 1, 4, 5, 8, 10, and 11 despite blood pressure readings well above those thresholds.
On July 11, R40's blood pressure measured 119/72 — far above the parameters that would warrant the medication. Yet registered nurse RN-M administered it anyway around 7:15 a.m.
When questioned, RN-M claimed he had taken a different blood pressure reading but couldn't produce documentation or remember the numbers.
The director of nursing confirmed the medication should not have been given since the documented blood pressure readings were higher than the allowable parameters for administration.
Other monitoring failures emerged during the inspection. R73, a resident with heart failure, was supposed to be weighed three times weekly to detect dangerous fluid retention. Records showed the resident missed 11 required weigh-ins over six weeks in June and July.
R138, another heart failure patient, was ordered to receive daily vital signs including weight monitoring. The resident's last recorded weight was June 10. When staff finally weighed R138 during the inspection on July 11, they discovered a 12-pound weight gain that had gone undetected for over a month.
The weight gain could signal worsening heart failure requiring immediate medical intervention.
R138 also faced pressure ulcer risks due to inadequate repositioning and toileting. The resident's care plan called for assistance every 2-3 hours to prevent skin breakdown, but during a four-hour observation period, no staff approached R138 for toileting or repositioning.
When nursing assistant NA-C was asked about R138's care, she couldn't remember bringing the resident to the bathroom. The assistant did offer toileting when prompted by investigators, but R138 initially refused.
The director of nursing confirmed that residents with memory impairment should be encouraged and reapproached after refusal, noting that regular repositioning and toileting was "important to keep skin intact."
One resident's case highlighted delays in specialty care coordination. R121, recovering from spinal surgery complications and a bloodstream infection, continued taking antibiotics without an end date while staff struggled to schedule a follow-up infectious disease appointment.
The resident had seen an infectious disease specialist on June 11, but the progress note from that visit wasn't uploaded to the facility's electronic health record due to technical problems. Without access to the specialist's recommendations, clinical staff couldn't properly monitor R121's ongoing antibiotic treatment.
Staff finally scheduled a follow-up appointment for August 20 — more than two months after the initial visit — and only after investigators questioned the delay.
The medical records staff person acknowledged being overwhelmed with uploading responsibilities, stating "that's the problem with just one of me here to upload everything."
The inspection revealed systemic breakdowns in basic nursing home operations: medication administration, treatment documentation, patient monitoring, and care coordination. In each case, residents faced increased risks due to staff failures to follow established protocols and accurately document care provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehab from 2024-07-11 including all violations, facility responses, and corrective action plans.