Northwoods Lodge

Inspectors wroteBased on record review and interview, the facility failed to notify the resident/resident's representative and Ombudsman in writing of the reason for the transfer/discharge to the hospital, convey the required information to the hospital and provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 34, 68, 18 and 66 ) when reviewed for hospitalization. These failures placed the residents at risk for lacking knowledge regarding their transfer, discharge rights and the right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents and/or resident representatives were provided education about COVID-19 vaccination, including risks, benefits and potential side effects for 4 of 5 sampled residents (Resident 2, 27, 54 and 16) reviewed for COVID-19 immunizations. Additionally, for facility staff the facility failed to annually screen and offer the COVID-19 vaccination (or provide information on where the vaccine could be obtained) and document if the vaccine was accepted/declined. These failures denied the residents and/or their representative and staff the right to make informed decisions.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 5 of 17 sample residents (Resident 16, 69, 74, 72 & 2) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to constipation, target behaviors for psychotropic (drugs that affect behavior, mood, thoughts, or perception) medication use, activities, and weights monitoring, placed residents at risk for unidentified and/or unmet care needs and potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently offer/provide showers and provide timely meal assistance to 3 of 3 Residents (Resident 72, 74 and 21) reviewed for activities of daily living (ADL). These failures placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 1 of 6 sampled residents (Resident 69) reviewed for bowel management and for 1 of 2 sampled residents (Resident 74) reviewed for edema and/or weight monitoring. The failure to initiate bowel care in accordance with physician's orders and the facility's bowel protocol, and the failure to obtain and evaluate weights, and notify the provider of weight variances as ordered, placed residents at risk for delayed identification and treatment of fluid volume overload, and abdominal pain, nausea, and decreased appetite related to untreated constipation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a safe environment was maintained related to falls for 1 of 1 sampled resident (Resident 21) when reviewed for accident hazards. This failure placed the residents at risk for avoidable injuries and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide non-pharmacological interventions (NPI) prior to the use of as needed pain medications for 4 of 6 residents (Residents 30, 74, 5 and 2) when reviewed for unnecessary medication. This failure placed the residents at risk of receiving unneeded medications and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' records were complete and accurate for 2 of 2 residents (Residents 54 and 2) reviewed for accurate and complete records. Failure to maintain complete and accurate records placed residents at risk for unmet care needs and for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Physical Therapy (PT) and Occupational Therapy (OT) services according to the care plan for 2 of 4 residents (Resident 1 and Resident 2) reviewed for specialized rehabilitation services. This failure placed residents at risk for delayed progress towards goals, a longer stay at the facility, and a diminished quality of life. <Resident 1> Resident 1 admitted to the facility on [DATE] with diagnoses of left humerus (long bone in upper arm) fracture and left hip fracture. The admission Minimum Data Set (MDS, an assessment tool) dated 06/03/2025, showed Resident 1 was cognitively intact and needed limited assistance for Activities of Daily Living (ADL's). Resident 1 was admitted for PT and OT with a goal of improving function and returning to the community. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement measures to prevent development of avoidable pressure ulcers and to thoroughly assess, monitor and obtain timely treatment orders for pressure ulcers for 1 of 4 sampled residents (Resident 38) reviewed for pressure ulcers. Resident 38 experienced harm when they developed two avoidable pressure ulcers which required hospitalization for surgical intervention and intravenous (in the vein) antibiotics.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 33 & 103) reviewed for IV therapy. The failure to ensure IV orders included routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and initial and then weekly measurements of IV catheters external length and the residents arm circumferences, placed them at risk for loss of vascular access, infection, and other potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were appropriate for the use of mobility bars, for 1 or 3 residents (Resident 103) reviewed for physical restraint, and to ensure prior to use of mobility bars that residents were evaluated for risk of entrapment and informed consent was obtained for 3 of 3 residents (Residents 103, 8 & 33) reviewed for physical restraint. This failure placed residents at risk for not knowing risks of mobility bars, accidents/harm/entrapment related to mobility bars, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare and serve food to residents in accordance with professional standards for 1 of 1 kitchen and 2 of 2 unit refrigerators/freezers reviewed for food service safety. The failure to maintain documented refrigerator, freezer and dishwasher temperatures, prevent contamination of uncovered foods during transportation, to throw out expired foods and maintain sanitary conditions placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure transmission based precautions (TBPs, extra precautions to prevent spread of infection) were implemented consistently and as indicated for 3 of 3 sampled residents (Residents 105, 40,33) reviewed for aerosol generating procedures (AGPs, procedures that generate aerosols that could be infectious), 2 of 3 sampled residents (Residents 17 &33) reviewed for enhanced barrier precautions (EBPs, infection control precaution of wearing gown and gloves during high contact activities during resident care) and 1 of 2 sampled residents (Resident 38) reviewed for contact precautions (infection control precaution of wearing gown and gloves before room entry and while in room) observation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship program had an accurate and complete antibiotic line listing, with symptoms and McGeers Criteria (tool for infection surveillance and antibiotic stewardship, provided criteria to show if antibiotics were indicated) reviewed, and providers were updated on residents that did not meet criteria for antibiotic usage, for 3 of 3 residents (Resident 30, 354, & 355) reviewed for antibiotic line listing. This failure placed residents at risk of developing multi-drug resistant organisms, unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 5 for 6 sampled residents (Resident 21, 156, 154, 40 & 25) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident choices regarding bathing type were honored for 1 of 4 sampled residents (Resident 103) reviewed for choices. The facility's failure to accommodate resident preferences related to type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 2 of 2 sampled residents (Residents 30 & 40), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 2 sampled residents (40 and 30) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan, within 48 hours of admission, that included instruction needed to properly care for 1 of 11 residents (Resident 105) reviewed for new admission. This failure placed residents at risk for unidentified and unmet needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person-centered comprehensive care plans that identified resident specific care needs and interventions for 1 of 4 residents (Resident 13) reviewed for activities of daily living. The failure to identify residents' self-care deficits, and develop and implement interventions to meet their needs, placed residents at risk for feelings of helplessness, frustration, decreased intake/weight loss and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to re-assess and revise the care plan for 1 of 7 residents (Resident 23) reviewed for care planning. This failure placed residents at risk for skin impairment related to immobility, for delay in care services, and for a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 35 sampled residents (Residents 105, 33, 304 & 49) reviewed. The failure of nursing staff to follow and/or clarify incomplete physicians' orders, to accurately document the medication dose that was administered, and to notify the provider of trendable medication refusals, placed residents at risk for medication errors, adverse side effects, unmet care needs and other potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pharmacological and non-pharmacological interventions were implemented for 2 of 7 residents (Residents 45 and 8) reviewed for bowel managment. This failure placed the residents at risk for discomfort, constipation, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety precautions were followed prior to administering enteral (tube feeding) nutrition for 1 of 1 resident (Resident 105 ) reviewed for enteral nutrition. The failure to validate enteral tube placement and to check gastric residuals (food, liquid, or material from a previous feeding left in the stomach at the start of the next feeding) placed residents at risk for increased abdominal distention, reflux (stomach acid coming up from the stomach into the esophagus), aspiration, respiratory compromise and other potential adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for continuous positive airway pressure (CPAP) machine settings and oxygen orders for use including label/date, oxygen tubing/supplies and nasal cannula (NC, flexible tubing that sits inside the nose and delivers oxygen) for 2 of 5 sampled residents (Resident 21 & 40) reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident 30) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the assessed level of supervision required to ensure residents were free from avoidable accidents for 1 of 3 residents (Resident 1) reviewed for accident hazards. Additionally, the facility failed to document supervision for 2 of 2 residents (Residents 1 & 2) reviewed for accident hazards. Resident 1 experienced harm when they fell from bed and sustained a hip fracture, pain, and hospitalization. This failure placed residents at risk for injury and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for 4 of 5 residents (1, 2, 3, & 4) reviewed for abuse, neglect and accidents. The failure to thoroughly investigate an allegation of staff to resident mistreatment, identify the alleged perpetrator (AP), and implement interventions to ensure the alleged victims (AV) and other residents' safety, placed residents at risk for continued abuse/neglect, psychosocial harm, accident risk, and decreased quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when a change of condition was not addressed timely for 1 of 3 residents (Resident 1) and when neurological (neuro) assessments were not consistently performed following unwitnessed falls for 3 of 3 residents (Resident 1, 2, and 3) reviewed for quality of care. Resident 1 experienced harm when they had to be emergently transferred to the hospital when they had a significant change in their baseline cognition and status following an unwitnessed fall. These failures placed residents at risk for medical complications, poor clinical outcomes, unmet care needs, pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices were assessed and monitored in accordance with professional standards of practice for 3 of 3 residents (Residents 40, 206 and 46) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet the immediate care needs for 2 of 15 residents (Residents 206 & 102) reviewed for care planning. This failure placed the residents at risk for medical complications and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 21 sampled residents (Residents 34, 102 and 40) reviewed. The failure to follow, obtain, and/or clarify incomplete physicians' orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 102) reviewed for respiratory care and services, was provided such care, in accordance with professional standards of practice. The failure to obtain the prescribed pressure settings for resident's continuous positive airway pressure (CPAP/an external device that provides a fixed pressure to keep breathing airways open while you sleep) machine, precluded staff from validating the CPAP was correctly programmed and the resident received the amount of positive airway pressure they had been assessed to require. This failure placed residents at risk for ineffective assisted ventilation and unmet respiratory needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and that expired medications were discarded for 2 of 2 (South cart and [NAME] cart) medication carts observed. These failures placed residents at risk to receive expired medications and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to assess, monitor and implement interventions to mitigate worsening of a non-pressure skin issue for 1 of 4 sampled residents (Resident 1) reviewed for quality of care related to skin and wound management. This failure placed residents at risk for unidentified wound decline, infection, and diminished quality of life.