North Woods Village

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 2 of 2 residents reviewed for care plans. (Resident 12 and 13)Findings include: 1. The clinical record for Resident 12 was reviewed on 3/16/26 at 1:40 p.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), traumatic brain injury, and diabetes mellitus. The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 5/2/25. There was no care plan located in Resident 12's electronic record related to post-traumatic stress disorder. During an interview, on 3/19/26 at 11:18 a.m., RN 5 indicated she was not sure what Resident 12's trauma triggers were related to the diagnosis of PTSD, and she would have to look it up on the computer. During an interview, on 3/20/26 at 10:00 a.m., the DON indicated Resident 12 was admitted with a diagnosis of PTSD, and a care plan was not added until 3/17/26 for her trauma and triggers. She did not have a care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure blood pressures were obtained and documented prior to administering a blood pressure medication with parameter orders and to ensure a physician's order was followed according to the medication parameters for 2 of 6 residents reviewed for quality of care. (Residents 95 and 69)Findings Include: 1. The clinical record for Resident 95 was reviewed on 3/17/26 at 10:43 a.m. The diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, and Parkinson's disease.A care plan, dated 5/29/24, indicated Resident 95 was at risk for ineffective tissue perfusion related to high blood pressure. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 2/11/26, indicated to administer 60 milligrams (mg) of nifedipine (a medication used to treat high blood pressure) every morning and to hold the medication if the systolic blood pressure was less than 130.The Medication Administration Record (MAR), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 2 of 3 residents reviewed for misappropriation of property. (Resident B and C) The deficient practice was corrected on 7/29/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 12/16/25 at 11:34 a.m., the Director of Nursing (DON) indicated Resident B had requested a pain pill on 7/26/25. LPN 4 was unable to find her oxycodone (narcotic pain medication) or the medication count sheet. LPN 4 called the pharmacy and was informed Resident B should have the narcotics available at the facility. LPN 4 then reported the missing narcotics and an investigation was started. During the investigation, it was discovered Resident C also had narcotic medication and a medication count sheet missing. The facility determined LPN 2 had stolen the narcotics. LPN 2 was terminated from the facility.1. The clinical record for Resident B was reviewed on 12/16/25 at 1:30 p.m. The diagnoses included, but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a medication for blood pressure was held according to the physician's ordered parameters for 1 of 1 resident reviewed for quality of care. (Resident 100) Findings include: The clinical record for Resident 100 was reviewed on 3/4/25 at 10:41 a.m. The diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder, familial dysautonomia, and chronic systolic congestive heart failure. An Emergency Department After Visit Summary, dated 1/11/25, indicated the resident was seen for a headache and his blood pressure was higher than the normal range during the visit. A physician's order, dated 1/13/25, indicated to give midodrine (a medication used to increase blood pressure) 10 milligrams (mg) three times per day with special instructions to hold the medication if the systolic blood pressure was greater than 120. The Medication Administration Record (MAR), dated January 1 through 31, 2025, indicated a midodrine dose was not held: a. On 1/14/25 at 1:00 p.m., with a systolic blood pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a portable oxygen tank was turned on to administer the correct flow rate for 1 of 1 resident reviewed for respiratory care. (Resident 4) Findings include: During an observation, on 3/2/25 at 10:25 a.m., Resident 4 was in the hallway in her wheelchair at the nurse's medication cart with QMA 2 receiving her medications. The resident had a nasal cannula in her nose with a portable oxygen tank hanging on the back of her wheelchair. The flow rate on the portable tank was set at zero (0) liters/minute. QMA 2 administered medications to Resident 4 and signed the medication administration record (MAR). QMA 2 did not look at the portable oxygen tank to verify the amount of oxygen the resident was receiving. During an observation, on 3/2/25 at 12:15 p.m., the resident wheeled herself past 2 nurses and a certified nursing assistant (CNA) and greeted them as she entered the dining room for lunch. The nasal cannula was in her nose, and the portable oxygen tank on the back of her wheelchair was still set at zero (0)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff wore gloves when touching a resident's medication for 1 of 9 residents observed for medication administration. (Resident 3) Findings include: During an observation, on 3/2/25 at 10:12 a.m., QMA 2 removed the resident's medication from the medication cart. She placed the card of multivitamin 7.5 milligrams (mg) iron with 400 micrograms (mcg) of folic acid in her right hand. QMA 2 used her right hand and popped the pill from the card into her left bare hand. She took the pill with her fingers and placed the pill into the medication cup. During an interview, on 3/2/25 at 10:14 a.m., QMA 2 indicated she should have used gloves and not touched the pill with her bare hands. The clinical record for Resident 3 was reviewed on 3/2/25 at 10:12 a.m. The diagnoses included, but were not limited to, diabetes mellitus, atrial fibrillation, and anxiety disorder. A physician's order indicated to give a multivitamin 7.5 milligrams (mg) iron and 400 micrograms (mcg) folic acid tablet daily. A current facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify the resident's representative of a psychotic disturbance and the start of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 89). Finding includes: The clinical record for Resident 89 was reviewed on 3/13/24 at 4:44 p.m. The diagnoses included, but were not limited to, nondisplaced fracture of the right femur, major depressive disorder, generalized anxiety disorder, cognitive communication deficit and dementia with psychotic disturbance. A physician's order, dated 1/4/24, indicated to give Risperdal (an antipsychotic medication) 0.25 milligram (mg) at bedtime for dementia with psychotic disturbance. A physician's order, dated 1/25/24, indicated to give Risperdal 0.5 mg at bedtime for dementia with a psychotic disturbance. A physician's order, dated 2/7/24, indicated to give Risperdal 1 mg twice a day. A Pharmacy Consultation Report, dated 1/14/24, indicated the resident received Risperdal 0.25 mg at bedtime for dementia with psychotic disturbance. Antipsychotics had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to correctly code an annual Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for Preadmission Screening and Record Review (PASARR) (Resident 9). Finding include: The clinical record for Resident 9 was reviewed on 3/13/24 at 9:20 a.m. The diagnoses included, but were not limited to, unspecified dementia with mood disturbance, insomnia, bipolar disorder, major depressive disorder, and psychotic disorder with delusions. A notice of PASARR level 2 outcome, with a notice date of 12/23/22, indicated the resident had a long-term approval without specialized services based on the diagnoses of bipolar disorder NOS (not otherwise specified), unspecified depressive disorder, dementia NOS, unspecified insomnia disorder, and for treatment history, current symptoms, and service needs. An annual MDS assessment, dated 1/10/23, indicated the resident was not currently considered by the state level 2 PASARR process to have a serious mental illness and/or intellectual disability or related condition. During an interview, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen was on the correct liter flow per the physician's orders for 1 of 1 residents reviewed for respiratory care (Resident 60). Findings include: During an observation, on 3/13/24 at 11:03 a.m., Resident 60's oxygen was at 1 liter flow. The clinical record was reviewed on 3/13/24 at 11:17 a.m. The diagnoses included, but were not limited to COPD, chronic respiratory failure with hypoxia, and influenza due to novel influenza A virus. A physician's order, with a start date of 2/21/24 and an end date of 3/13/24, indicated the resident was to wear oxygen at 2 liters per nasal canula continuously. A physician's order, started on 3/13/24 at 9:17 a.m., indicated the resident was to wear 2 liters of oxygen per nasal canula at bedtime. During an observation and interview, on 3/13/24 at 2:20 p.m., the DNS (director of nursing services) saw and indicated the resident's oxygen was on 1 liter. During an interview, on 3/13/24 at 2:21 p.m., the DNS indicated the resident had a continuous oxygen order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff were documenting resident behaviors, implementing and documenting nonpharmacological interventions for behaviors, and failed to ensure potential side effects of an antipsychotic medication were documented and assessed for a resident with dementia for 1 of 5 residents reviewed for dementia care (Resident 75). Findings include: During an observation, on 3/12/24 at 10:31 a.m., the resident was sitting up in her wheelchair in the activity room. The resident was continuously rocking herself back and forth in the wheelchair. The resident was very fidgety and pulling at a blanket while continuously moving her hands. During an observation, on 3/12/24 at 10:57 a.m., the resident was still in the dining area and was fidgeting with a napkin on the table and the blanket on her lap and making constant movements with her body. During an observation, on 3/13/24 at 1:58 p.m., the resident was sitting up in her wheelchair in the common area at a table by herself. The resident was constantly touching a piece of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medication carts were free of loose pills and opened medications were dated for 1 of 3 medication carts reviewed for medication storage (The Walnut Unit and a combined medication cart for the [NAME] and Magnolia Units). Findings include: During a medication storage observation with the Qualified Medical Assistant (QMA) 4 on 3/14/24 at 11:10 a.m., the Walnut unit cart was observed to have the following: a. The second left large drawer had 17 loose pills on the bottom. b. The third left large drawer had 33 loose pills and 13 half tablets on the bottom of the drawer c. The third right drawer had a bottle of opened Milk of Magnisium (MOM) for Resident 89 opened and not dated. The record for Resident 89 was reviewed on 03/14/23 at 11:40 a.m. A physician order, dated 12/28/23, indicated to give MOM 400 Milligram(mg)/5 Milliliter(ml) daily when needed. During an interview, on 3/14/23 at 11:23 a.m., QMA 4 indicated the pills should not be in the bottom of the cart. The pills should be destroyed in a jug in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store clean clothing or resident personal care items in a clean environment for 4 of 117 residents (Residents 2, 14, 52, and 76). Findings include: 1. During an observation on 03/11/24 at 01:15 p.m., clean clothes were hanging from one end of the shower curtain rod to the other over the bathtub in the bathroom of Residents 2 and 52. Blankets and a large black trash bag of items were in the bathtub. The toilet had armrests attached, no lid, and was positioned immediately beside the bathtub. Multiple items of clean hanging clothes were touching the armrest of the toilet. At least half of the hanging items were within the contamination splash zone of the flushing toilet of less than 3 feet. During an observation on 03/12/24 at 09:37 a.m., clean clothes continued to hang from one end of the shower curtain rod to the other over the bathtub, were touching the armrest of the toilet, and were within the splash zone of the flushing toilet. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.