Northwood Skilled Nursing and Rehabilitation

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to store, prepare, and serve food in a safe and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 69. Observation 06/14/26 at 8:58 A.M. of the walk in cooler revealed lemonade that was undated, chicken salad with a discard date of 06/11/26, and coleslaw with a discard date of 05/26/26. Interview on 06/14/26 at 8:59 A.M. with Dietary Supervisor (DS)#273 verified the lemonade did not have a date and that the chicken salad and coleslaw should have been discarded. Observation on 06/14/26 at 9:01 A.M. revealed a can of shasta cola stored under raw meats of the walk in cooler. Interview with DS #273 verified the soda should not have been stored below raw meat. Observation on 06/14/26 at 9:01 A.M. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents residing in the facility. The facility census was 69. Observation on 06/14/26 at 8:56 A.M. revealed several gnats flying around near the dish machine. Interview on 06/14/26 at 9:25 A.M. with Dietary Supervisor #273 verified they have been having a problem with gnats in the dish washing area and he was planning to have the pest control company come out to treat the area. Review of the pest control reports since 02/19/26 revealed fly activity was observed in the kitchen on 02/19/26, 04/10/26, and 06/02/26. Review of the facility policy titled, Sanitization dated October 2008 revealed all kitchen areas will be kept clean and protected from rodents, roaches, flies, and other insects.

Inspectors wroteBased on record review, interview and facility policy review the facility failed to ensure a safe smoking environment when residents had their own cigarettes and lighter, this affected three residents (#32, #43, and #68), the facility also failed to maintain a smoking blanket in good condition, this had the potential affect all twenty residents ( #01, #02, #05, #06. #07, #11, #12, #16, #19, #24, #29, #32, #39, #40, #42, #43, #47, #50, #67, and #68) the facility identified as smokers , and the facility failed to accurately assess one resident (#45) for wandering/elopement. The facility census was 69.

Inspectors wroteBased on review of the menu, review of the menu spread sheet, observation, and staff interview, the facility failed to follow menus for residents with a pureed diet. This affected five (#28, #33, #37, #44, and #45) of five residents the facility identified with an order for a puree diet. The facility census was 69. Review of the menu for 06/15/26 revealed lunch was garlic herb beef pot roast, mashed potatoes, normandy vegetable blend, wheat bread, brown gravy, and oreo cookie blodies. Review of the menu spread sheet for 06/15/26 revealed residents with a puree diet should recieve pureed pot roast, mashed potatoes, pureed veggie blend, pureed bread, brown gravy, and pureed blondie. Observation on 06/15/26 12:00 P.M. revealed residents with a puree diet were not being served bread and were served apple sauce as a substitute for the cookie blondie. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to residents with a dignified dining experience. This affected one (#26) of the 13 residents reviewed for dining. The facility also failed to ensure resident rights were honored. This affected one (#45) of the one reviewed for resident rights. This facility census was 69.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident receiving psychotropic medications signed a consent for the use of those medications, and after the risks and benefits associated to their use were explained to the resident/resident's responsible party. This affected one (Resident #08) of five residents reviewed for unnecessary medications. The facility census was 69.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the state mental health authority via a Pre-admission Screening and Resident Review (PASARR) process when a resident had a significant change in condition which resulted in a new diagnosed mental health condition. This affected one resident (#03) of two residents reviewed for PASARR. The facility census was 69.

Inspectors wroteBased on medical record review, staff interview, resident interview, and facility policy review the facility failed to complete comprehensive care plans for residents. This affected four Residents (#45, #02, #33, and #09) of the four residents reviewed for care plans. The facility census was 69.

Inspectors wroteBased on record review, resident and staff interview, the facility failed to ensure pain was managed as ordered, this affected one (Resident #05) out of one reviewed for pain management. The facility census was 69.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to act upon recommendations made by the pharmacist. This affected one (Resident #03) of five residents reviewed for unnecessary medications. The facility census was 69. Review of the medical record for Resident #03 revealed an admission date of 02/24/25 with diagnoses of schizoaffective depressed type, epilepsy and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the medication regimen review (MRR) for Resident #03 on 10/01/25 revealed phenytoin level on next convenient laboratory (lab) day and every six months. There was no physician response or signature. [...]

Inspectors wroteBased on record review, resident interview, observation, staff interview, and facility policy review, the facility failed to provide Resident #1 a therapeutic diet as ordered by the physician. This had the potential to affect 16 residents that the facility had identified with an order for a therapuetic diet. The facility census was 69. Review of Resident #1's medical record revealed an admission date of 04/04/26 with diagnoses including polyneuropathy, hypokalemia, and pneumonia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resdient #1 was cognitively intact. Review of the physician order dated 05/26/25 revealed Resident #1 was ordered a regular diet, mechanical soft texture, regular consistency with extra gravies, sauces, etc. to further moisten foods. [...]

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure residents signing binding arbitration agreements understood the agreement. This affected two residents (#48 and #62) of five residents reviewed for arbitration. The facility census was 69. 1. Review of the medical record for Resident #48 revealed an admission date of 11/04/25 with diagnosis of non-Alzheimer's dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. Review of the Arbitration Agreement revealed the agreementwas signed by Resident #48 on 11/19/25 at 1:17 P.M. Interview on 06/16/26 at 8:25 A.M. with Admissions Director #203 confirmed Resident #48 resided in the memory care. Interview on 06/16/26 at 8:45 A.M. [...]

Inspectors wroteBased on medical record review, staff and resident interview and policy review, the facility failed to ensure they were free from significant medication errors when the nurse failed to administer medications according to the physician orders. This affected six (#39, #05, #49, #10, #40, #75) of seven residents reviewed for late medications. The census was 76.

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure residents with enhanced barrier precautions (EBP) had clear signage or instruction indicating required personal protective equipment (PPE) and care activities that require what PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy. This affected 11 (#02, #05, #06, #10, #12, #19, #34, #36, #56, #68 and #73) of 11 residents reviewed for EBP. Additionally, the facility failed to clean and disinfect durable medical equipment (DME) between residents. This affected two residents (#14 and #78) of three reviewed. The facility also failed to ensure gloves were changed in between residents and hands were washed in-between resident care and after resident care. This affected one (#72) of three resident reviewed for incontinence care. The facility census was 76.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure timely incontinence care was provided. This affected one (#72) of three residents reviewed for incontinence. The census was 76.

Inspectors wroteBased on medical record review, observation, staff interview, review of the water temperature logs, and review of a plumbing invoice, the facility failed to ensure water temperatures were within normal limits. This affected one (#72) of three residents reviewed for water temperatures. The census was 76.

Inspectors wroteBased on medical record review, observation, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure staff provided adequate supervision and intervention to prevent Resident #01, who had impaired cognition, was at risk for elopement, was housed on a secured memory care unit and who had a history of eloping from his bedroom window, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and/or injury when the resident was displaying a change of condition and was observed pacing near the nurse's station and the resident was noted to be observing Licensed Practical Nurse (LPN) #110 closely. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 71 residents who reside at the facility. The facility census was 71.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. [...]

Inspectors wroteBased on observations, medical record review, resident and staff interview, and policy review, the facility failed to ensure a call light was in place for a resident. This affected one (#68) of 24 residents reviewed for call light placement. The facility census was 76.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete an accurate Pre-admission Screen and Resident Review (PASARR) for Resident #62. This affected one (Resident #62) of two residents reviewed for PASARR. The facility census was 76.

Inspectors wroteBased on resident and staff interview, and record review, the facility failed to allow the participation of the resident and/or resident representative in the comprehensive care plan when there was no evidence a care plan conference was conducted. This affected two (Resident #47 and #68) of two residents reviewed for care plan conferences. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and review of the hospice contract, the facility failed to ensure hospice services were provided and documentation of the services and care provided to a resident receiving hospice services were available at the facility. This affected one (Resident #15) of two residents reviewed for hospice services. The facility census was 76.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to follow appropriate infection control techniques when they failed to cleanse their hands after changing gloves and failed to appropriately clean a wound for Resident #64. This affected one (Resident #64) of three residents reviewed for skin conditions The facility census was 76.

Inspectors wroteBased on medical record review, resident and staff interviews, resident representative interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the bed hold policy upon the residents' discharge to the hospital. This affected four (Residents #16, #18, #69, and #76) of four residents reviewed for bed hold notification. The facility census was 76.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure residents were free from prolonged quarantine. This affected three (Residents #2, #7, and #18) of five residents in quarantine. The census was 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities were completed as scheduled and met the needs of the residents. This affected three (Residents #10, #43 and #47) of 54 residents in the facility. The census was 54.

Inspectors wroteBased on record review and interview, the facility failed to timely address a resident's pain. This affected one (Resident #203) of one resident reviewed for pain management. The census was 54.

Inspectors wroteBased on record review and staff interview, the facility failed to attempt non-pharmacological interventions before administering an as needed anti-psychotic medication. This affected one (Resident #38) of five residents reviewed for unnecessary medications. The facility census was 54.

Inspectors wroteBased on record review and staff interview, the facility failed to have labs drawn as ordered. This affected two (Residents #9 and #13) of five residents reviewed for unnecessary medications. The facility census was 54.

Inspectors wroteBased on observation and interview, the facility failed to display the state survey agency information, including information on filing a complaint with the state survey agency in a conspicuous area that was readily available to residents and their representatives. The affected all 54 residents in the facility.

Inspectors wroteBased on observation, resident and staff interview and record review the facility failed to post the past survey results in a conspicuous area that was readily available to residents and their representatives. The affected all 54 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to update the daily posted staffing. The affected all 54 residents in the facility.