The Sapphire at Northwoods

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a process for monitoring cool-down and reheating temperatures for leftovers was implemented and failed to ensure opened foods were labeled and stored in a food-safe manner. This has the potential to effect all residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative services were provided for three of four residents (R1, R3, R4) reviewed for restorative services in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to implement fall interventions to prevent and/or minimize injury due to falls for 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 6. These failures resulted in R1 sustaining a fall resulting in multiple vertebral fractures which lead to his demise.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was used or discarded by the use by date, failed to sanitize food preparation equipment, failed to take/record food temperatures prior to serving it, and failed to ensure individuals in the kitchen wear hair nets. These failures have the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees were provided with education and offered the COVID-19 vaccine and failed to document their COVID-19 vaccination status. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a resident centered activity program with meaningful activities for residents with diagnoses of dementia. This applies to 4 of 18 residents (R92, R16, R35, R34) reviewed for activities in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff removed personal protective equipment (PPE) when exiting an isolation room and failed to securely wear a N95 mask by not placing both loops around their head. The facility failed to ensure staff washed their hands and wore the required PPE when entering an isolation room. This applies to 4 of 18 residents (R39, R74, R2 and R41) reviewed for infection control in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident had a PASARR Screening (Preadmission Screening and Resident Review) done after his initial PASARR Screening gave approval for only a 60-day admission to a nursing facility. This applies to 1 of 4 residents (R4) reviewed for PASARR Screenings in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter drainage bag was kept off the floor for 1 of 2 residents (R13) reviewed for indwelling urinary catheters in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received fortified food for 1 of 5 residents (R64) reviewed for nutrition in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a blood pressure medication was administered according to order parameters for 10 of 31 days resulting in a significant medication error because of the frequency of the error. This applies to 1 of 18 residents (R24) reviewed for pharmacy services in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin pens were dated when opened to 3 of 5 residents (R2, R7, R51) reviewed for medication storage in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were assessed and offered pneumococcal immunizations upon admission for 2 of 5 residents (R16 and R41) reviewed for vaccinations in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their nurse staffing was posted on a daily basis. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to assess, intervene and implement treatments in a timely manner for a resident (R2) found to have a new injury/bruising to her left shoulder which resulted in a delay in the diagnosis of and treatment of R2's left shoulder dislocation. This failure applies to 1 of 5 residents (R2) reviewed for the necessary care and services in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to care for a resident (R2) in a safe manner which resulted in R2 sustaining a left shoulder dislocation. The facility failed to ensure a resident (R2) was safely repositioned in bed, as directed per the resident's care plan. These failures apply to 1 of 5 residents (R2) reviewed for resident safety and supervision in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to inform a resident's representative of new a injury/bruise found to a resident's shoulder for 1 of 1 residents (R2) reviewed for a resident change in condition in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7.

Inspectors wroteBased on interview and record review the facility to ensure a resident with acute delusions was monitored and supervised. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3.

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident (R2) was free from physical abuse for 2 of 6 residents (R1 and R2) reviewed for abuse in the sample 6.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure safe incontinence care for 1 of 3 residents (R1) reviewed for safety. This failure resulted in R1 rolling off the bed onto the floor and sustaining a cervical fracture, a left clavicle fracture, and laceration to her left eyebrow requiring 3 sutures.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep a resident free from physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to identify pressure injuries prior to a stage 3 for a resident at risk for pressure with a history of pressure (R1). This failure resulted in a delay in assessing and obtaining treatment orders to prevent pressure injuries from worsening for R1. The facility failed to ensure pressure interventions were in place for a resident with a left heel pressure injury (R72). This applies to 2 of 5 residents (R1, R72) reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to notify the dietician in a timely manner of a resident with a significant weight loss of 8 lbs. (pounds) 6.2% in one month. This failure resulted in a delay in dietary interventions being implemented and an additional 3.4 lb. 2.81% weight loss in one week. This applies to 1 of 18 residents (R77) reviewed for weight loss in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a non-pressure wound dressing was changed per physician orders. This applies to 1 of 18 residents (R83) reviewed for skin conditions in the sample of 18.

Inspectors wrote2. On 10/21/24 at 11:10 AM, R30 was in bed watching television. R30 had an orange extension cord plugged into the upper wall outlet. The cord went behind and under R30's bed. Plugged into the extension cord was a non-medical grade power strip. The power strip had R30's bed and pressure relieving air mattress plugged into it. R30 stated she has the air pump mattress due to a pressure wound on her heel. On 10/22/24 at 10:10 AM, R30's room still had the orange extension cord and power strip in the same location as 10/21/24. On 10/22/24 at 11:30 AM, V1 Administrator stated medical devices need to be plugged into a medical grade power strip. The facility did not provide a power strip policy at the time of the survey. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the bedside suction was maintained for a resident with a history of pneumonia which applies to 1 of 1 residents reviewed for suctioning in a sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the required Personal Protective Equipment (PPE) was worn when providing care to residents on Enhanced Barrier Precautions for 2 of 8 residents (R46, R72) reviewed for infection control in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to identify and treat a pressure ulcer for a resident dependent on staff for care. This failure resulted in R1's pressure ulcer to his right heel not being identified until it was necrotic and unstageable on 3/18/24. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen floors, appliances, and areas of the ceiling were clean and free of debris. The facility failed to ensure containers of opened, refrigerated condiments were stored and maintained in a sanitary manner. The facility failed to store dry foods in a manner to prevent cross-contamination. These failures have the potential to affect all 75 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the facility's roof to ensure a safe, comfortable environment for 4 of 18 residents (R47, R49, R18, R40) reviewed for environment in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure resident assessments were accurate for 2 of 18 residents (R72, R57) reviewed for minimum data set (MDS) assessments in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided incontinence care in a timely manner for 2 of 18 residents (R30, R22) reviewed for Activities of Daily Living (ADL) in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility to failed to report a change in a resident's skin condition to ensure treatment for that resident's cellulitis was initiated in a timely manner for 1 of 18 residents (R47) reviewed for necessary care and services in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were rinsed and dried after using soap for incontinence care for 2 of 5 residents (R53, R30) reviewed for incontinence care in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure residents understood the language and content of a binding arbitration agreement prior to signing the agreement for 3 of 3 residents (R180, R179, R55) reviewed for binding arbitration agreements in the sample of 18.