Northridge Health Center, The

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, incident file review, and staff interview, the facility failed to ensure comprehensive resident centered care plans were developed to address resident medical and psychosocial needs.

This affected one (#70) of four residents reviewed for care plans.

The facility census was 69.Findings include:

Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, cocaine use, type II diabetes, and morbid obesity.

Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact and required extensive assistance to complete activities of daily living. Resident #70 discharged to the community on 05/01/25.Review of a progress note dated 01/30/25 from Resident #70's emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use.

The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting.

Review of the incident file for Resident #70 revealed that on 04/28/25, Resident #70 was found smoking an illicit substance in his room at the facility.

When confronted, Resident #70 did not deny his drug use.

Review of the care plan for Resident #70 revealed no care plans with goals or interventions related to Resident #70's history of or continued drug use.Social Worker #700 verified Resident #70's medical record lacked a care plan with goals and interventions for drug use during an interview conducted on 08/29/25 at 2:11 P.M.This deficiency represents non-compliance investigated under Complaint Number OH00165746 (1393119).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Northridge Health Center, The

35990 Westminster Ave North Ridgeville, OH 44039

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility policy titled, Incontinence care policy, dated December 2023, revealed the policy was to provide individualized incontinence care based on a comprehensive assessment and care plan.

Residents will be offered timely assistance, appropriate continence aids, and preventative skin care to promote health, comfort, and dignity.

The procedures included to provide timely and respectful assistants for toileting, changing, and hygiene needs.

Staff are to change incontinent products promptly when soiled to prevent odor, discomfort, and skin irritation.This deficiency represents non-compliance investigated under Complaint Number 2572439, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Northridge Health Center, The

35990 Westminster Ave North Ridgeville, OH 44039

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 09/04/25 at 1:55 P.M. with Maintenance Director #293 measured the distance between Resident #23's bed and the bathroom and revealed the distance was approximately seven feet.

Interview on 09/04/25 at 2:02 P.M. with the DON confirmed an assessment was not documented on Resident #23 until 04/29/25 at 4:01 P.M. and revealed she did not have an answer why.

The DON revealed she came in the facility that night, she took over for the nurses who went to the hospital to be assessed due to exposure.

Neither Resident #70 nor Resident #23 were sent to the hospital.

The DON revealed she saw Resident #23 sleeping in bed and had no concerns.

The DON revealed she worked the remainder of the night until 6:30 A.M. the following morning as the charge nurse and revealed Resident #23 was not woke up during that time for a physical assessment.

Telephone interview on 09/04/25 at 5:13 P.M. with LPN #202 revealed on 04/28/25 she was one of the nurses who witnessed Resident #70 smoking an illegal substance in his bathroom. LPN #202 revealed the roommate (Resident #23) was lying in his bed and revealed Resident #23 was not wearing his CPAP but he had his oxygen on with his nasal cannula. LPN #202 revealed Resident #23 often refused his CPAP and revealed he may have worn it later that night but at that time he did not have it on. LPN #202 revealed Resident #70 was smoking the substance in the bathroom sitting in his wheelchair just inside the doorway of the bathroom, the door was opened, and as soon as she entered the doorway of Resident #70's and Resident #23's room, she could smell the odor of the illegal substance and seen Resident #70 smoking from the pipe.

The deficiency represents non-compliance investigated under Complaint Number 2600408, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Northridge Health Center, The

35990 Westminster Ave North Ridgeville, OH 44039

SUMMARY STATEMENT OF DEFICIENCIES

Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and cognitive skills were severely impaired. Resident #72 was dependent for eating, toileting hygiene, and bed mobility. Resident #72 received oxygen therapy continuous.

Review of the care plan for Resident #72 dated 09/01/25 revealed the resident had potential for complications related to diagnoses of COPD, asthma, and emphysema.

Interventions included to administer medications, inhalers as ordered, and to give oxygen as ordered.

Review of the physician orders for Resident #72 dated 08/30/25 revealed an order for oxygen delivery via nasal cannula with a liter flow of two liters and the duration was continuous every shift for breathing.

Observation on 09/03/25 at 9:56 A.M. revealed Resident #72 was lying in bed. Resident #72's eyes were closed.

Observation revealed Resident #72's oxygen concentrator was running.

The nasal cannula was lying on the floor under the tube feeding pole next to Resident #72's bed. Resident #72 was not receiving oxygen from the concentrator.

Observation on 09/03/25 at 9:57 A.M., as surveyor was exiting the room, revealed Licensed Practical Nurse (LPN) #202 was walking towards the surveyor and entered Resident #72's room. LPN #202 confirmed she was Resident #72's primary care nurse that day. LPN #202 walked over to Resident #72's bed, proceeded to shut off the tube feeding, then exited the room without addressing Resident #72 nasal cannula on the floor at the bottom of the tube feeding pole. LPN #202 returned to the medication cart and proceeded to walk up the hall, away from Resident #72's room pushing the cart.

The Surveyor immediately approached LPN #202 and requested information about Resident #72's oxygen therapy. LPN #202 revealed she was not sure if Resident #72 was supposed to receive oxygen.

LPN #202 opened Resident #72's physician orders on her computer located on the medication cart and revealed Resident #72 had an order to be on oxygen continuously.

After requesting LPN #202 to assess Resident #72's oxygen status, LPN #202 returned to Resident #72's room and verified the oxygen tubing was on the floor. LPN #202 then monitored Resident #72's oxygen saturation level (percentage of oxygen in the blood) via a pulse oximeter and confirmed Resident #72's oxygen saturation was between 86 percent (%) and 88%. LPN #202 revealed Resident #72's oxygen saturation level was 95% that morning when she assessed it. LPN #202 obtained new oxygen tubing and connected the tubing to the concentrator then placed the cannula in Resident #72's nostrils. LPN #202 then exited the room.

Observation revealed the concentrator was set at 1.5 liters per minute.

The surveyor immediately returned to LPN #202 who returned to the medication cart.

When asked how many liters per minute of oxygen Resident #72 should be receiving, LPN #202 again stated she was not sure and again pulled the order up on the computer on the medication cart. LPN #202 revealed Resident #72 should be on two liters of oxygen per minute per the physician orders. LPN #202 returned to Resident #72's room and confirmed the oxygen was set at 1.5 liters per minute.

Review of the facility policy titled, Oxygen Administration, revised 10/2022, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration.

Staff are to verify the physicians order for the procedure and turn the oxygen on as directed by the Medical Practitioner.

The deficiency represents an incidental finding discovered during the investigation for Complaint Number OH00165746 (1393119).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Northridge Health Center, The

35990 Westminster Ave North Ridgeville, OH 44039

SUMMARY STATEMENT OF DEFICIENCIES

insulin appears at the tip.

Repeat priming if no insulin appears.The deficiency represents non-compliance investigated under Master Complaint 2601734, Complaint Number 2572439, and Complaint Number OH00165746 (1393119).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Northridge Health Center, The

35990 Westminster Ave North Ridgeville, OH 44039

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited NORTHRIDGE HEALTH CENTER, THE in NORTH RIDGEVILLE, OH for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-09-11.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of NORTHRIDGE HEALTH CENTER, THE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.