North Central Health Care

Inspectors wroteBased on interview and record review, the facility did not conduct a thorough investigation of resident (R) R1's missing money of $115.00 as reported by R1 on 02/13/26. The facility did not interview other residents on unit to ensure no other concerns, risks or trends were identified. The facility policy titled: Nursing Home Abuse, Neglect, Misappropriation, Exploitation, Resident to Resident Altercations, Injury of Uknown Origin, and Caregiver Misconduct, last reviewed on 08/07/25, states in part: 4.3. Prevention and Monitoring: Monitoring will include the identification of any department, caregiver, and/or resident trends. On 01/07/2026, R1 was admitted to facility for orthopedic aftercare. R1's admission Minimum Data Set (MDS) indicated R1 had a Brief Interview for Mental Status (BIMS) score of 14/15 (cognitively intact). [...]

Inspectors wroteThe facility did not provide adequate supervision to prevent accidents for 2 of 4 sampled residents (R51 and R3). R51 sustained four falls without adequate supervision or a root cause being determined, the last fall resulted in R51 suffering major injury, causing R51's overall decline and admission to hospice services. This is being cited at actual harm. R3 had multiple falls, the care plan was not updated with the interventions to prevent falls.

Inspectors wroteBased on record review and interview, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process after each Minimum Data Set (MDS) assessment for 4 of 4 residents (R6, R2, R3, and R48) reviewed for care conferences. This is evidenced by:The facility's policy titled Person centered Service Policy dated 04/01/24, read in part. 2. Definitions, Care Plan: An individual plan for each resident describing goals, interventions, approaches built by the Interdisciplinary team (IDT) with input from the resident or resident representative. Resident's Goal: The resident's desired outcomes and preferences for admission, which guide decision making during care planning. Resident's goals may change throughout their nursing home stay and are reviewed quarterly at care conferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all 119 residents in the facility.-Clean linens were not covered in the facility's laundry room where dirty fans were blowing on the linens.

Inspectors wroteBased on interview and record review, the facility did not complete the proper discharge process for 5 of 5 residents (R) reviewed for discharge. (R124, R6, R2, R43, R126) R124 transferred out of the facility and did not receive written discharge documentation. R6 was transferred to the hospital on [DATE] and 01/17/25 did not receive written notice of transfer or bed hold reserve payment notice. R2 was transferred to the hospital on [DATE] and did not receive written notice of transfer or bed hold reserve payment notice. R43 was not given a notice of transfer when sent to the hospital on 6/22/25. The ombudsman was not notified of R126's discharge. According to federal regulation 483.15(c)(3), resident/representative needs to be provided with a written Notice of Transfer (and/or discharge as appropriate) in a manner they could understand, and which meets all the notice requirements. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect 45 residents who eat on the second floor of the north wing out of 119 residents that reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching foods with contaminated gloved hands.

Inspectors wroteBased on interview and record review, the facility did not immediately report to the physician on call for a change in respiratory patterns and gastrointestinal (GI) issues for 1 out of 12 residents (R) (R105) reviewed for change in condition. -Facility did not notify physician on call for the numerous events of Respiratory Therapist (RT) F manually bagging R105 during respiratory distress for long periods of time. -Facility did not notify physician on call for the numerous times R105 had no Bowel Movement (BM) and signs of abdomen distention.

Inspectors wroteBased on interview and record review, the facility did not ensure that the PASRR (Pre-admission Screen and Resident Review) Level I screen for 1 of 1 resident (R82) reviewed was conducted accurately for having mental illness or developmental disability. R82's PASRR Level I screen was not completed accurately, resulting in the screen not being submitted to the appropriate agency for further review. Findings Include:The Pre-admission Screen and Resident Review (PASRR) Level 1, revised in 7/2017, states the following: Federal law requires that all persons requesting admission to a nursing facility must be screened to determine the presence of a major mental illness and/or developmental disability. If on the Level 1 a resident is marked for Yes in section A, under Current Diagnosis, then the Level I must be referred to PASRR Contractor for a Level II Screen. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 of 24 residents (R) reviewed (R18, R19) were provided the necessary services to maintain personal hygiene.-The facility did not develop and implement interventions in accordance with R18's needs related to toileting and repositioning.-The facility did not implement interventions in accordance with R19's assessed needs related to toileting and repositioning.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being. The facility did not ensure a resident received gastrointestinal (GI) assessments and treatment promptly for bowel issues for 1 of 24 residents (R) reviewed. (R105)Surveyor reviewed the facility protocol titled Bladder and Bowel Management, last reviewed on 08/06/25, which states in part, .Bowel Management-Each shift to review EMR documentation an devaluate need for interventions. If no BM by AM Day 2: Offer/encourage prune juice and increase fluid intake. If not effective by PM Day 2: Offer oral laxative per MD order. If not effective by AM Day 3: Check for stool in rectum, give suppository or enema per MD order. If constipation persists: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure a resident with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent further reduction in ROM for 1 of 3 residents (R). (R13)-R13's restorative plan was not implemented. R13 did not receive right hand splint for 10 of the last 19 days. The facility policy, titled Restorative Nursing, dated 01/11/23, states: . Programs are to be planned, scheduled, and documented in the medical record. Team member will complete the Restorative Program as indicated in the Comprehensive Care Plan. Documentation will be completed in Matrix. R13 was admitted to the facility on [DATE], with diagnoses that include stroke with one sided paralysis, Parkinson's disease, encephalopathy, epilepsy, and COPD. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 3 residents (R), (R2) reviewed with a Foley catheter. This is evidenced by:Facility policy titled Urinary Catheters revised date 08/06/25, read in part. General Care. Follow enhanced barrier precautions, perform handy hygiene before and after. Emptying of Bag. Disinfect the drainage port with an alcohol-based wipe after each use. R2 was admitted to the facility on [DATE]. R2's current diagnoses include cystitis, bladder-neck obstruction, disease of intestine, and reduced mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standards of practice were followed for verification of gastrostomy placement before medication administration for 1 of 3 residents (R) reviewed for tube feeding. (R105) Registered Nurse (RN) E did not check placement of the G-tube (A G-tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) according to professional standards of practice prior to administering medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 24 residents (R1) reviewed. The facility did not ensure Registered Nurse (RN) E completed training before working on the ventilator unit where R1 resides. R1 was admitted on [DATE] and then readmitted on [DATE], with diagnoses in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R) (R1.) On [DATE], staff transferred R1 utilizing the incorrect sling type during a Hoyer lift transfer from chair to bed. As a result, R1 fell out of the incorrect Hoyer sling, hitting the right side of her face on the leg of the Hoyer lift. R1 had injuries of a nosebleed, and bruising to both eyes, forehead, and cheekbone. R1 expired on [DATE]. The medical examiner documented the cause of death as consequence of witnessed fall and complications of closed head injury. The facility's failure to ensure R1 had the correct type of sling for a safe Hoyer transfer created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare and distribute foods in a sanitary manner. The facility's practices have the potential to affect 111 residents who eat orally. Cook F's facial hair/mustache was observed uncovered in the facility's kitchen where foods are prepared and stored. Equipment in the kitchen was observed uncovered while not in use in areas where food is prepared which has the potential for contamination of the equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly prevent the spread of infections as evidenced by failure to sanitize mechanical lifts between 4 residents (R16, R62, R85, R71), did not provide hand hygiene for 6 of 111 residents (R109, R67, R22, R111, R112, R80) before eating, and did not perform proper hand hygiene between glove changes during cares for 1 resident (R71).

Inspectors wroteBased on record review and interview, the facility did not provide adequate supervision to prevent resident to resident incidents for 1 of 9 residents reviewed for accidents (R109). This is evidenced by: Surveyor requested and reviewed the facility policy which addresses resident to resident altercations. The policy titled Nursing Home Abuse, Neglect, Misappropriation, Exploitation, Resident to Resident . Resident to Resident Altercation: Negative, aggressive and intrusive verbal, physical material and sexual interactions between residents that in a community setting would likely be unwelcomed and potentially cause physical or psychological distress or harm in the recipient. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not implement adequate supervision to prevent avoidable accidents for 1 of 1 resident (R1) reviewed. The facility was aware of R1's wandering behavior and R1's previous sexual encounter with a resident when R1 wandered into R2's room, entered the bed with R2, and placed her hand down R2's donned brief. The facility did not implement an intervention to increase supervision of R1.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure safe and sanitary conditions for dishwashing; this has the potential to affect 103 of 113 residents in the facility. The facility did not consistently monitor daily dishwashing rinse temperatures according to standards of practice, or take action when the rinse temperature was less than 180 degrees. The Wisconsin Food Code requires the temperatures to be at least 180 degrees for the rinse cycle. Findings as follows: During survey from 5/15/23 through 5/17/23, Surveyor reviewed dish machine temperature logs for the month of May 2023 for 4 dishwashing machines in the nursing home. Each log indicates information stating: The final rinse should be 180° and not go over 200°. The dish machine will need to be run at least 2 times to get up to temperature before you can run dishes. [...]