Northern Lights HCC

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed (R1.) R1 was a 2 person assist for transfers with the EZ stand lift. Certified Nursing Assistant (CNA) H independently transferred R1 with the EZ stand and R1 fell resulting in a 3.5 cm x 4 cm laceration of the left temporal scalp requiring transfer to the local hospital for treatment consisting of 7 staples to the temporal scalp. This is evidenced by:Facility policy titled Mechanical Lifts (Total Body and Sit-to-Stand) with a reviewed date of 04/2026 states: All mechanical lifts will be operated per the manufacturer's instructions. Sit to Stand: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 (R3) of 4 sampled residents reviewed for falls/accidents out of a total sample of 6 residents. R3 was diagnosed with a right hip fracture, identified as an injury of unknown origin and the facility did not report the injury to the state agency (SA). CMS's definition of abuse to be reported within 2 hours, as identified, in part, by 483.12(c)(1) as: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 3 residents sampled. (R1)Facility did not consistently monitor and assess R1 for changes after testing positive for COVID-19. The provider was not notified when R1 began experiencing COVID-19 symptoms. This is evidenced by:Facility policy, titled, Notification of Change, with a revision date of 11/2022, states in part: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 2 of 3 residents (R) reviewed (R1 and R3). On 07/31/25, R3 had a fall resulting in fracture and treated in ER. The facility did not report this incident as possible neglect to State Agency (SA). On 10/10/25, the facility was made aware of a concern of neglect regarding R1's care. The facility did not report this allegation of neglect to State Agency. This is evidenced by:Facility policy, titled, Abuse, Neglect, and Exploitation, Suspected Crime, with a revised date of 08/2025, states in part: [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of neglect was thoroughly investigated for 2 of 3 residents (R) (R1 and R3) reviewed. On 10/10/25, the facility was made aware of a concern of neglect regarding R1's care. The facility did not ensure a thorough investigation was completed related to the allegation of neglect of R1. On 07/31/25, R3 had an unwitnessed fall in R3's room. The facility did not ensure a thorough investigation was completed. This is evidenced by:Facility policy, titled, Abuse, Neglect, and Exploitation, Suspected Crime, with a revised date of 08/2025, states in part: It is the policy of this community to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R) (R1, R2, R3) reviewed. R1 experienced a fall resulting in a head laceration and transfer to the emergency room (ER) for treatment. The facility did not complete a thorough investigation into root cause, implement new safety interventions, and assess head wound. R2 experienced numerous falls and the facility did not complete a thorough investigation into root cause or implement new safety interventions to prevent further falls. R3 experienced numerous falls, one with a major injury, and did not complete a thorough investigation into root cause or implement new safety interventions to prevent further falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect 42 out of 43 residents that eat orally at the facility. A fan in the clean dish washing station, which had notable dust and debris, was blowing on a rack of clean dishes. The cook did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. A dietary aide was observed not properly wearing a beard restraint. This is evidenced by: Example 1 The facility policy titled, “Food Safety- Director of Food and Nutrition Services’ Responsibilities” dated 2021, states in part, “5. Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment… 8. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for all 43 residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 8 of 9 residents (R30, R29, R13, R18, R9, R16, R26 and R14) were treated with respect and dignity. Facility staff stood over R9, R16, R18, and R29 while assisting them to eat. Facility did not ensure residents (R30, R26, R13, R14) received meal within a similar time frame as others at the same table. Facility set up R13's meal uncovered at dining room table and R13 was not present.

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 1 resident (R) reviewed (R28). This is evidenced by:Facility policy titled, Abuse, Neglect, and Exploitation, Suspected Crimes, with a reviewed date of 11/2024, states: Procedure: 3. Prevention: a. Staff, families, and residents are encouraged to report incidents of suspected abuse, neglect.5. Investigation: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services for 1 of 13 residents (R)(R28) reviewed. R28's care plan interventions to offload heels while in bed was not updated when changed from using heel pads to wedge. This is evidenced by:Facility policy titled, Person-centered Plan of Care - Comprehensive, with a revision date of 01/2023, states: Person-centered Care: Integrated health care services delivered in a setting and manner that is responsive to the individual and their goals, values and preferences, in a system that empowers patients and providers to make effective care plans together. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not promote the prevention of or implement interventions to prevent pressure injuries for 2 out of 4 residents (R) reviewed for pressure injuries, (R5, R40) resulting in stage II pressure injuries (PI).

Inspectors wroteBased on interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 1 out of 5 residents (R)(R28). R28's passive range of motion (PROM) exercises and application of palm guard was not completed as ordered. This is evidenced by:R28 was admitted to the facility on [DATE], with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R28's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R28 had impaired range of motion (ROM) on both sides in upper and lower extremities. R28's care plan, dated 06/27/25, with a target date of 07/23/25, states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents (R)(R28 and R5) reviewed. R28 was not given enteral feeding as ordered and assessment was not completed per current standard of care. R5's assessment was not completed per standard of care. This is evidenced by: Facility policy titled, “Gastrostomy Tube - Administration of Medications,” with a revision date of 10/2022, states: “Medications administered via tube will be done following current standards of practice and with a physician’s order. Procedure: 5. Check for correct placement of tube.” The National Institute of Health, 2023, recommends the position of a feeding tube be checked by measuring the visible tube length and comparing it to the length documented during x-ray verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not recognize and manage pain for 1 of 1 resident reviewed (R53) in order to help attain or maintain highest practicable level of well-being and to prevent or manage pain. The facility failed to recognize and treat R53's pain and implement pain interventions.

Inspectors wroteBased on interview and record review, the facility did not provide a written notice of transfer to include reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman for 3 residents of 3 residents (R)(R4, R28, R32) reviewed. The facility did not have a system in place to provide a written notice of transfer. This had the potential to affect all 43 residents that reside in the facility. R4 was transferred to the hospital on [DATE]. No written notice of transfer was documented. R28 was transferred to the hospital on [DATE]. No written notice of transfer was documented. R32 was transferred to the hospital on [DATE] and 07/11/25. No written notice of transfer was documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident (R1) at risk for elopement, which resulted in R1 leaving the building unsupervised, putting R1 at risk for serious injury or death. -The facility did not ensure an unalarmed door was repaired to prevent residents from exiting without staff supervision. -The facility did not ensure R1's whereabouts were checked every 15 minutes as identified on the care plan. -The facility did not increase R1's supervision after R1 successfully eloped from the unalarmed door. The facility's failure to supervise a resident at risk for elopement created a finding of immediate jeopardy that began on 01/02/25. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on 01/22/25 at 11:05 AM. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and served under sanitary conditions. This practice had the potential to affect all 39 residents (R) residing in the facility. -Chocolate milk expired on 05/15/24, five days prior to observation. -Dishwasher temperature logs were not completed. -Internal dishwasher temperatures were not routinely checked. -During tray line service in the kitchen, the maintenance director and a roofer carrying a ladder, entered the kitchen without hairnets. The roofer used the ladder to remove a ceiling tile in the kitchen and view the ceiling above, while speaking with the maintenance director. The roofer then replaced the ceiling tile and exited the kitchen. -A dietary aide did not wear hairnet appropriately. -The cook touched ready to eat food with contaminated gloved hands.

Inspectors wroteBased on interview and record review, the facility did not ensure the mandatory staffing data submitted was complete, accurate, and auditable. This has the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility did not implement restorative and Functional Maintenance Programs (FMP) in attempt to improve or maintain residents' functional abilities. The facility practice has the potential to affect 13 of 39 sampled and supplemental sampled residents (R5, R21, R12, R25, R15, R22, R9, R28, R30, R32, R17, R27 and R16). This is evidenced by: The facility restorative program was reviewed. According to this program, The goal of a Restorative Nursing Program is to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable . Example 1 Surveyor observed R5 throughout survey in various locations including in bed in her room, in the front lobby and in the dining room for meals. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide sufficient staffing to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This has the potential to affect 14 of 39 residents (R5, R21, R12, R25, R15, R22, R9, R28, R30, R32, R17, R27, R16, and R89) that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that written bed hold notice and reason for transfer required for facility-initiated transfers was provided to the residents or resident representatives at time of hospital transfer or within 24 hours of transfer for 2 of 2 residents (R19 and R33) reviewed for hospitalization. This is evidenced by: The facility policy, entitled Bedhold with effective date of December 28, 2016, states: In the event a resident is temporarily absent from Northern Lights for hospitalization or therapeutic leave you will be offered the opportunity to reserve your residency this action is known as a bed hold. Northern Lights prior to or at time of temporary discharge will provide the resident or the representative a written notice specific to behold to include duration and financial obligation as well as the readmission process. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not provide assistance with activities of daily living (ADL) for residents who are dependent on staff. The facility practice affected 3 of 4 residents observed for ADLs (R5, R29, R16). This is evidenced by: Example 1: R5's most recent comprehensive annual Minimum Data Set (MDS) completed 4/25/24 notes: Dependent on staff for hygiene Range of Motion (ROM) 1/2 Indicating impairment of 1 side upper extremities and 2 sides lower extremities. R5's care plan included the following: Focus: Actual/At risk and/or potential for complications with deficits with ADL's (Activities of Daily Living) related to current medical/physical status Goal: Will have needs anticipated and met through review date Initiated: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 2 residents reviewed for wounds (R16) received the necessary treatment and services to promote healing of existing skin integrity impairment according to current standards of practice when not repositioned and nursing staff did not follow infection control practices during wound care. This is evidenced by: The Wound Care Education Institute (WCEI), 2018, directs the caregiver for Non-Sterile dressing changes in the following manner: The purpose of non-sterile dressings is to protect open wounds from contamination and absorb drainage . 5. wash hands and apply gloves .9. Remove soiled dressing .10. Remove gloves, wash hands, apply new gloves .12. Clean wound with normal saline or prescribed cleanser. 13. Pat tissue surrounding the wound with dry 4 x 4 gauze .16. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 2 residents reviewed for wounds (R89) received the necessary treatment and services to promote healing of existing Stage IV pressure injuries (PIs), according to current standards of practice. - R89 has three Stage IV and two Stage II PI's. Two continuous observations were conducted by the surveyors in which R89 was not offered or encouraged to reposition or offload the buttocks in order to redistribute pressure over the area to allow for healing; - A new wound developed and was given an incorrect anatomical location; - The wound nurse inaccurately staged the wounds; and - Registered Nurse (RN) P completed dressing changes on the wound and did not practice appropriate hand hygiene and completed the treatment inaccurately. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, 2 of 5 residents (R11 and R14) reviewed for unnecessary medications were not comprehensively assessed or adequately monitored for sleep disturbance with use of medications to promote sleep This is evidenced by: Surveyor requested and received the facility policy titled Psychotropic Medication Use dated April 28, 2021. The policy in part read: Procedure: ~The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in long term care facility . ~The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacological medication use. ~Nursing: Monitors psychotropic drug use daily. [...]

Inspectors wroteBased on observation, record review and interview, staff did not perform hand hygiene when warranted when providing care to 1 of 6 residents observed for care (R5). Certified Nursing Assistants (CNA) E and F did not perform hand hygiene when warranted when providing morning care to R5. This is evidenced by: Surveyor requested and received the facility policy tiled Alcohol Based Hand Rub dated most recently as June 23, 2020. The policy in part read: Policy: It is the policy of Northern Lights Health Care to promote and maintain infection control standards to prevent the spread of infection. Procedure: ~Alcohol Based Hand Rub (ABHR) may be used to clean hands in those situations when soap and water is unavailable, with limited resident contact or while performing tasks with a resident and the ability to wash hands at a sink is not possible. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure residents received appropriate treatment and services to maintain or prevent further reduction in range of motion (ROM). This had the potential to affect all residents (R) that have a functional maintenance program (FMP) or restorative need. The facility did not provide services or treatment for residents (R35, R18, R36, R13, R28, R1, R9, R14, R2, R5, R145, R31, R25, R4), identified with a need for FMP or restorative program. This is evidenced by: R35 admitted to facility on 11/8/23 after fall at home resulting in fracture of right-side collar bone and multiple ribs. R35 admitted with right arm sling. Minimum Data Set (MDS) confirmed R35 scored 5/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that each resident was assessed for eligibility and offered a pneumococcal immunization to prevent pneumonia for 2 of 5 residents (R) reviewed for immunizations. R18 and R39.

Inspectors wroteBased on record review and interviews, the facility did not ensure residents were free from resident-to-resident abuse. The facility did not evaluate incidents of resident-to-resident altercations in attempt to prevent further abuse. The facility did not evaluate Resident (R) 29's incidents of verbal and physical altercations with peers and provide evidence of interventions to prevent future occurrences. This is evidenced by: The facility policy, entitled Abuse Investigations, dated 06/02/2021, states: Within 24 Hours: The facility will take all necessary actions as a result of the investigation, including analyzing the occurrence to determine the reason that the abuse occurred, and what changed needed to be made to prevent further occurrences. Defining how the care systems and process will be changed to protect residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for 1 of 3 residents (R144). R144's baseline care plan did not identify treatment for right extremity arm sling, including parameters when sling should be applied or removed and correct placement of sling. This is evidenced by: R144 was admitted to the facility on [DATE], after brief hospitalization following a fall at home, resulting in fracture of right upper arm, and fracture of left wrist. R144 was admitted with left wrist cast and right extremity sling. Minimum Data Set (MDS), dated [DATE], confirmed R144 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R144 is her own decision maker. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not ensure quality of care was provided for 1 of 2 residents (R144). R144's care plan did not identify treatment for right extremity arm sling. Sling was not placed correctly, resulting in pain, bruising, edema, and new order to apply tubigrip (an elastic tubular bandage) to right extremity. This is evidenced by: R144 was admitted to the facility on [DATE], after brief hospitalization following a fall at home, resulting in fracture of right upper arm, and fracture of left wrist. R144 was admitted with left wrist cast and right extremity sling. Minimum Data Set (MDS), dated [DATE], confirmed R144 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R144 is her own decision maker. On 5/8/23 at 12:26 PM, Surveyor observed R144 in her room, sitting in her wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received adequate interventions to prevent accidents. R35 sustained six falls since admission; there were no new interventions added to R35's plan of care to prevent falls. This is evidenced by: A review of the facility Fall Management Policy. dated April 28, 2021, stated, in part: .6. Identify root cause of fall. 7. Review fall prevention interventions and modify plan of care. 8. Communicate to all shifts that resident has fallen and newly implemented interventions. 11. All falls will be reviewed at management meetings and any further interventions that may be beneficial will be identified and care plan updated. R35 admitted to facility on 11/8/23 after fall at home resulting in fracture of right-side collar bone and multiple ribs. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that its staff demonstrates proper disposal of sharps to prevent the spread of disease and infections for 1 of 3 residents (R) observed, R12. The nurse discarded a used lancet, a needle device for obtaining a blood sample, in a standard garbage at the resident's bedside.