North Winds Living Center

Inspectors wroteOn 05/12/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident from psychosocial abuse for Resident #2. A nurse note, dated 02/13/25 at 4:00 p.m., showed Resident #79 was heard yelling come out your room mother [explicit]. The note showed Resident #79 stated, get out here faggot. The note showed LPN #1 approached Resident #79 who was repeating come the [explicit] out, I'm gonna [explicit] you up. The note showed Resident #79 was holding a wet floor sign in their hand, slinging it around, and attempting to get into another resident's room. The note showed the other resident did nothing and kept their door shut. The note showed Resident #79 threw the wet floor sign at the door which hit LPN #1 on the lower right leg. The note showed three staff attempted to calm them down. [...]

Inspectors wroteOn 05/12/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to thoroughly investigate an allegation of abuse for Resident #2. A nurse note, dated 02/13/25 at 4:00 p.m., showed Resident #79 was heard yelling come out your room mother [explicit]. The note showed Resident #79 stated, get out here faggot. The note showed LPN #1 approached Resident #79 who was repeating come the [explicit] out, I'm gonna [explicit] you up. The note showed Resident #79 was holding a wet floor sign in their hand, slinging it around, and attempting to get into another resident's room. The note showed the other resident did nothing and kept their door shut. The note showed Resident #79 threw the wet floor sign at the door which hit LPN #1 on the lower right leg. The note showed three staff attempted to calm them down. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's complete advance directive was included in their medical record for 1 (#2) of 16 sampled residents reviewed for advance directives. RN #1 identified 27 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident's oxygen tubing was changed according to the standard of practice and physician order for 1 (#18) of 1 sampled resident reviewed for oxygen use. RN #1 identified 27 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not administered the wrong medications for 1 (#4) of 6 sampled residents reviewed for medication administration. RN #1 identified 27 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure EBP (Enhanced Barrier Precaution) signage was in place to ensure appropriate usage of PPE, for 1 (#24) of 1 sampled resident reviewed for infection control. RN #1 identified 27 residents resided in the facility. On 05/04/25 at 8:17 a.m., Resident #24 was observed in their room, on their bed under the covers, and did not respond to questions. No observation of EBP signage inside the residents room or anywhere outside of the residents room. On 05/05/25 at 12:33 p.m., there was no EBP signage on the outside of Resident #24's room/door. There was a three drawer plastic cabinet in the hall located next to the room which contained gowns, shields, masks, and gloves. Resident #24 stated the staff tape the port for showers. [...]

Inspectors wroteBased on record review and interview, the facility failed to utilize an infection assessment screening to identify whether or not antibiotics were necessary for 2 (#6 and #10) of 5 sampled residents reviewed for antibiotic stewardship. The Resident Matrix, dated 05/04/25, showed 11 residents with infections resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan had been developed/revised for a resident who received dialysis for one (#8) of 28 residents reviewed for care plans. The Resident Matrix dated 02/12/24, documented 28 residents resided in the facility. One resident received dialysis.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's code status was identified in their health record for one (#19) of 16 sampled residents reviewed for code status. The Resident Matrix, dated 02/12/24, documented 28 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident before and after dialysis for one (#8) of one sampled resident reviewed for dialysis services. The Resident Matrix, dated 02/12/24, documented 28 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete annual skills competency for two (CNA #1 and CNA #2) of two CNAs whose employee files were reviewed for skills competencies. The Resident Matrix, dated 02/12/24, documented 28 residents resided in the facility. There were four CNA's documented on the staff roster who had been employed over one year.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for one (#2) of three sampled residents reviewed for medication administration. The Resident Matrix, dated 02/12/24, documented 28 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure: A. Residents were offered the opportunity to take part in their care plan meeting for two (#17 and #19) of three sampled residents reviewed for care plan meetings and, B. Care plans were revised with each resident assessment for three (#1, 13 and #24) of nine sampled residents reviewed for care plan revision. The Resident Census and Conditions of Residents report, dated 01/17/23, documented 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure collaboration and coordination of care and services with hospice was provided for one (#4) of one sampled resident who was admitted to hospice services. The Resident Census and Conditions of Residents report, dated 01/17/23, documented two residents were receiving hospice care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a significant change assessment was conducted for one (#4) of one sampled resident reviewed for hospice services. The Resident Census and Conditions of Residents report, dated 01/17/23, documented two residents were receiving hospice care.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurate for one (#19) of nine sampled residents reviewed for resident assessments. The Resident Census and Conditions of Residents report, dated 01/17/23, documented 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan for hospice care for one (#4) of one sampled resident who was reviewed for hospice service. The Resident Census and Conditions of Residents report, dated 01/17/23, documented two residents were receiving hospice care.