The patient, identified as R45, returned from the hospital with discharge papers clearly indicating the dialysis shunt had been removed and treatments were no longer needed. Despite this, nursing staff continued documenting dialysis care tasks from July 1 through July 8.
Director of nursing confirmed during a July 11 interview that staff had falsely documented the dialysis tasks as completed. She told inspectors she "couldn't explain why staff had documented the tasks as completed" and said her expectation was for staff to complete assigned tasks and document accurately.
The facility's own policy from September 2023 required comprehensive care plans for residents with end-stage renal disease that reflected their dialysis needs. The policy specifically directed staff to document post-dialysis weight, bleeding at access sites, complications, or if a resident was unable to accept dialysis treatment.
Staff were also required to report changes in condition to the MDS coordinator for care plan review, according to facility policy.
The director of nursing explained that admission nurses typically handled all admissions and readmissions. When residents returned during evenings or weekends, floor nurses completed necessary assessments while a second nurse reviewed documents and performed accuracy checks, including full head-to-toe assessments.
She emphasized the importance of accurate documentation for medical record integrity and preventing potentially harmful outcomes to residents.
The false documentation violation was discovered alongside widespread cleanliness failures throughout the facility's locked memory care unit, where 36 residents live.
A family member told inspectors on July 8 that the facility was "always dirty and had an odor of urine in the hallways." The relative said she cleaned her family member's room herself "or it would be dirty also."
Inspectors documented extensive contamination across the memory care unit over multiple days. The dining room carpet contained various crumbs, debris, and an approximately 2x2 inch piece of white and yellow paper under a table. Numerous small, light-colored, powder-like spots covered the entire room.
Brown spots approximately 2 inches in diameter were found on the floor outside resident rooms. One room's wall showed two different shades of tan paint with uneven edges extending 1 to 3 inches from the ceiling.
A 4-foot section of wallpaper was missing from a dining room corner, exposing dried dark brown stains and opaque brown streaks running downward on the underlying wall.
Handrails showed contamination including a half-inch diameter dark brown spot with a 2-inch lighter smeared area. Light brown drip-like streaks covered approximately 2 feet of adjacent railing. These marks remained visible the following day.
Carpet between the dining room and resident rooms felt tacky when walked on, though no discoloration was visible.
Activity staff prepared to start programming in the dining room without wiping down tables after breakfast.
A registered nurse confirmed the brown spots on the floor "could not be cleaned because it was like glue now." She described the handrail contamination as "chocolate pudding or chocolate ice cream dessert" resembling a handprint about two fingers wide. The nurse used wet soapy paper towels to clean the area, noting residents frequently touched handrails.
Another nurse described the sticky carpet and identified the floor spots as spilled supplement from medication passes.
The housekeeping director confirmed food particles and crumbs on dining room floors after breakfast, missing wallpaper with liquid and solid spills on exposed walls, carpet spots that staff should have cleaned, and sticky carpet outside the dining room. She acknowledged handrails needed daily cleaning and disinfecting.
The administrator confirmed the unit carpet needed replacement but provided no timeline. He acknowledged the wallpaper was "not satisfactory or homelike" with mismatched colors. Missing exhaust fans caused odors, he said, though the facility was still obtaining repair quotes.
The administrator described missing endcaps on handrails that created blunt edges potentially causing injury. He said such issues should trigger critical work orders for immediate repair.
"It was not a homelike or welcoming environment," the administrator told inspectors.
The facility received minimal harm violations affecting few residents for the false documentation and some residents for the environmental failures.
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.
