Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ecumen North Branch during CMS and state inspections, most recent first.
A stack of steam table pans, labeled as clean and ready for use, was found stored with visible moisture on several pans. The director of culinary services confirmed these items should have been fully air dried and inspected for dryness before storage, in accordance with facility policy, but this process was not followed.
Laundry staff routinely left damp resident clothing, mop heads, and cleaning cloths in washing machines overnight, with the expectation that morning staff would transfer them to the dryer. This practice was confirmed by interviews with the DON, infection prevention nurse, and environmental services manager, and was not specifically addressed in the facility's laundry policy, despite written instructions prohibiting leaving damp linen in machines overnight.
The facility did not make the most recent survey results available for residents and visitors to review, as only outdated survey results were present in the binder at the front desk. The administrator confirmed that more recent recertification and complaint survey results were missing.
The facility failed to follow CDC guidelines during a COVID-19 outbreak, resulting in improper cohorting of residents and inconsistent PPE use by staff. Residents with positive and negative COVID-19 tests shared rooms, and staff did not consistently wear required PPE. Additionally, the facility did not conduct broad-based testing for staff, despite some working on multiple units.
A facility failed to assess a resident for self-administration of medications, despite the resident having severely impaired cognition and a history of respiratory issues. The resident was observed using a nebulizer without an assessment or order for self-administration. Staff confirmed the absence of a SAM order and stated that the nurse should be within eyesight during nebulizer use for safety. The facility's policy required an assessment for SAM, which was not conducted.
A resident admitted with acute on chronic diastolic congestive heart failure and requiring oxygen did not have a baseline care plan developed within 48 hours as required. The care plan was found blank a week after admission, lacking critical care information. Both an RN and the DON confirmed the oversight, and a policy on baseline care plans was not provided.
A facility failed to update a care plan for a resident with pressure ulcers, despite frequent refusals to wear prescribed Prevalon boots. The resident, with severe cognitive impairment and multiple health issues, was observed without the boots, and staff confirmed the refusals were not consistently documented. The facility's policy required care plan revisions with significant changes, which was not followed, leading to a deficiency.
A facility failed to follow provider orders for a resident with severe cognitive impairment and multiple health conditions. The resident did not receive prescribed PRN doses of furosemide for significant weight gain, and there were lapses in weekly skin assessments. The ADON acknowledged these deficiencies, citing staffing issues but emphasizing that it was not an excuse.
A facility failed to document and review a PRN opioid medication for a resident with paraplegia, anxiety, and depression. Despite being on a scheduled pain regimen, the resident had not used the PRN Oxycodone, and pain scores were frequently zero. Staff interviews revealed no clinical justification for the medication, and the pharmacy consultant recommended discontinuation due to non-use and potential risks. However, the provider denied the request, and the medication order remained active without proper documentation.
The facility failed to properly store and label resident food, as observed in unit refrigerators where items were found without proper labeling or dating. The culinary director admitted to not checking the fridges due to absence, and the administrator confirmed that staff should ensure food safety by checking dates. The facility's policy requires labeling and timely disposal of food to prevent food-borne illness.
A resident with impaired cognition and a history of falls was admitted without a comprehensive care plan addressing fall risks and interventions. Despite being identified as high risk for falls, the care plan and nursing assistant care sheet lacked necessary documentation. Interviews with facility staff confirmed the absence of required fall interventions, contrary to the facility's policy on managing falls.
Improper Storage of Food Preparation Items Due to Incomplete Drying
Penalty
Summary
During a kitchen tour with the director of culinary services, a stack of nine large steam table pans was observed on a storage rack, designated as clean and ready for food preparation. Upon inspection, five of the nine pans were found to have visible moisture, despite the facility's policy requiring all dishes to be completely air dried and inspected for dryness before storage. The director of culinary services acknowledged that the pans were not fully dry and confirmed that all dishes should be checked for dryness prior to being put away. The facility's Ware Washing policy, dated August 2023, specifies that dishes must be air dried and inspected for dryness before storage, a procedure that was not followed in this instance.
Damp Laundry Left Overnight in Washing Machines
Penalty
Summary
The facility failed to ensure that damp laundry, specifically resident clothing, mop heads, and cleaning cloths, was not left in washing machines overnight, contrary to facility policy. Laundry staff reported that it was routine practice to start a load of mop heads and cleaning rags in the washing machine at the end of their shift, leaving the items for the morning staff to transfer to the dryer the next day. Interviews with the Director of Nursing and the infection prevention nurse confirmed that the facility's laundry policy did not specifically address cleaning supplies, and both acknowledged the potential for bacterial growth when items are left damp for extended periods. The environmental services manager and administrator also confirmed this practice and indicated it could be changed if it was an infection prevention concern. The facility's written policy instructed that damp linen should not be left in washing machines overnight and that washing machine doors should be left open when not in use.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the previous year's survey results were available for residents and visitors to review. During an observation, it was noted that the survey results binder at the front desk only contained results from a survey conducted in the prior year, with no additional or more recent survey results included. Document review confirmed that the last recertification survey and two complaint surveys had been conducted after the date of the survey results present in the binder, but these were not available for review. In an interview, the administrator, who was responsible for maintaining the survey results binder, acknowledged that the most recent survey results were missing from the binder.
Inadequate COVID-19 Cohorting and PPE Compliance
Penalty
Summary
The facility failed to adhere to CDC recommendations for testing and cohorting during a COVID-19 outbreak, affecting several residents and staff. Specifically, the facility did not ensure proper cohorting of residents with confirmed COVID-19 infections, as evidenced by residents with positive and negative COVID-19 tests sharing rooms. For instance, Resident 7, who tested positive, shared a room with Resident 31, who tested negative. Similarly, Resident 39, who tested positive, shared a room with Resident 36, who tested negative. This improper cohorting was confirmed by the Director of Nursing (DON), who acknowledged that residents were more than six feet apart but did not move COVID-negative residents to separate rooms due to room availability. Additionally, the facility did not ensure that staff followed posted transmission-based precaution signs. Observations revealed that staff members, including nursing assistants and housekeepers, did not consistently wear the required personal protective equipment (PPE) when entering rooms with enhanced respiratory precautions. For example, a nursing assistant was observed wearing only a surgical mask instead of the required N95 respirator, gown, and gloves when exiting Resident 7's room. Similarly, a housekeeper entered and exited Resident 7's room wearing only a surgical mask, under the mistaken belief that PPE was only necessary for close-contact care. The facility also failed to conduct broad-based testing for staff during the outbreak, despite some staff working on multiple units and residents intermingling during group activities. The DON confirmed that staff were only tested if they exhibited symptoms or had a high-risk exposure, defined as being within six feet of a COVID-positive individual for more than 15 minutes. This approach was inconsistent with the CDC's guidance for managing a COVID-19 outbreak, which contributed to the potential spread of the virus within the facility.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively assess a resident for self-administration of medications (SAM), which is a requirement for ensuring the safety and appropriateness of medication management. The resident in question, identified as having severely impaired cognition and a history of respiratory failure, hemiplegia, and hemiparesis following a cerebral vascular accident, was observed using a nebulizer without a proper assessment or order for self-administration. The resident's care plan and medical records lacked documentation of an assessment for SAM, and there was no order permitting the resident to self-administer medications. Observations and interviews revealed that the resident was left alone with a nebulizer mask on, which was considered a form of self-administration by the facility's staff. The LPNs and the assistant director of nursing confirmed that the resident did not have an order for SAM and that the nurse should remain within eyesight of the resident during nebulizer treatments for safety reasons. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administering medications, which was not done in this case.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with acute on chronic diastolic congestive heart failure and required two liters of oxygen via nasal cannula. The resident's admission orders were dated 7/31/24, but as of 8/7/24, the baseline care plan was found to be blank, lacking essential information such as transfer status, activities of daily living performance, assistive device use, impairments, or special treatments like oxygen use. During interviews, both a registered nurse and the director of nursing confirmed that the baseline care plan had not been completed within the required timeframe, acknowledging the importance of timely care plan development to ensure proper resident care. A policy on baseline care plans was requested but not provided.
Failure to Revise Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident with pressure ulcers, leading to a deficiency in care. The resident, identified as having severely impaired cognition and multiple diagnoses including hypertension, chronic kidney disease, dementia, respiratory failure with hypoxia, peripheral vascular disease, and hemiplegia following a cerebral vascular accident, was dependent on staff for assistance with mobility and hygiene. The care plan included interventions such as offloading and repositioning every two hours, weekly skin inspections, and the use of Prevalon boots to prevent pressure ulcers. However, observations revealed that the resident was often not wearing the Prevalon boots as prescribed, and staff interviews confirmed that the resident frequently refused to wear them. Despite the resident's refusals, the facility did not update the care plan to reflect these challenges or document the refusals consistently. The assistant director of nursing acknowledged the importance of real-time updates to care plans to ensure appropriate care but noted that the resident's increased mobility made the boots cumbersome. The facility's policy required care plans to be reviewed and revised with significant changes in the resident's condition or when desired outcomes were not met, but this was not adequately done in this case, resulting in a deficiency.
Failure to Follow Provider Orders for Medication and Skin Assessments
Penalty
Summary
The facility failed to adhere to provider orders for a resident with severe cognitive impairment and multiple health conditions, including hypertensive heart disease, chronic kidney disease, and pressure ulcers. The orders included administering furosemide as needed for significant weight gain and conducting weekly skin assessments. However, the facility did not administer the prescribed PRN doses of furosemide on occasions when the resident experienced weight gains exceeding two pounds. Additionally, there were multiple lapses in performing the required weekly skin assessments over several months. The assistant director of nursing acknowledged these deficiencies, attributing them to the high use of licensed agency staff and a trained medication aid, although she emphasized that this was not an excuse. The facility's failure to follow the orders was confirmed during an interview, and the relevant policies were requested but not provided. The resident's care plan included interventions for monitoring weight and skin condition, but these were not consistently implemented, leading to the identified deficiencies.
Lack of Documentation for PRN Opioid Medication
Penalty
Summary
The facility failed to provide appropriate documentation and physician review for a PRN opioid medication ordered for a resident, identified as R11, who was cognitively intact and diagnosed with paraplegia, anxiety, and depression. Despite being on a scheduled pain medication regimen, R11 had not received any PRN pain medication or non-medication interventions for pain. The provider visit notes from February 2024 lacked documentation justifying the need for PRN Oxycodone for severe pain, and there were no notes available for a visit on February 23, 2024. The order for Oxycodone 5 mg by mouth twice daily as needed for severe pain was placed on February 23, 2024, and remained active despite R11's pain scores frequently being rated at zero, with occasional ratings between 1 and 4. The electronic medication administration record indicated that R11 had not taken the PRN Oxycodone since the order was placed. Interviews with staff revealed that the medication lists were monitored for unnecessary medications, including PRN pain medications like Oxycodone. However, there was no clinical documentation supporting the need for the PRN medication, and the nursing staff had not discussed the medication with the provider. The pharmacy consultant recommended reviewing and discontinuing the Oxycodone in July 2024, as it was not being utilized, but the request was denied by the provider. The pharmacy consultant noted the lack of documentation for the need of the medication and expressed concerns about the increased risk of addiction and diversion by keeping the medication order active. The assistant director of nursing stated that if a resident wanted to keep a medication active without utilizing it, the staff and provider needed to justify the medication or find a different intervention for the resident's comfort.
Failure to Properly Store and Label Resident Food
Penalty
Summary
The facility failed to ensure proper food storage practices in accordance with regulations for food safety, as observed during a survey. Specifically, the facility did not label and date resident food items and failed to remove expired food from unit refrigerators. During observations, a resident meal was found in the [NAME] unit refrigerator with a label and date, and in the Wild River unit refrigerator, a plastic container of blueberries with initials but no open date, and a hard plastic container of leftover green beans with a resident name and date were found. The culinary director (CD) acknowledged these issues, noting that leftover food should be discarded after three days to prevent food-borne illness, but admitted that he had been absent from work for a week and no one else checked the unit fridges in his absence. The facility's policy, as stated by the administrator, requires labeling food with the resident's initials and the date of opening, and the CD is responsible for checking unit fridges for expired food. However, the administrator also stated that staff should check food dates even when the CD is not present. The facility's 'Food from Outside Sources' policy mandates that personal food items be labeled with the resident's name and date, placed in an impervious container with a lid, and disposed of per the manufacturer's date or three days after marking. The policy also states that improperly packaged, labeled, or dated personal items will be discarded to maintain food safety and minimize the risk of food-borne illness.
Failure to Develop and Maintain Comprehensive Fall Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident identified as being at high risk for falls. The resident, who had impaired cognition and a history of falling, was admitted with a Minimum Data Set indicating these risks. However, the resident's care plan, dated June 10, 2024, lacked any information related to fall risk and fall interventions. Additionally, the nursing assistant care sheet, which was undated, indicated the resident was at high risk for falls but did not include any specific fall interventions. Interviews with facility staff, including a nurse practitioner, licensed practical nurses, registered nurses, and the assistant director of nursing, revealed that all residents should have documented fall interventions, especially those with a history of falls. The staff confirmed that the resident's care plan did not include necessary fall risk assessments or interventions, and there was a lack of documentation on the nursing assistant care sheet. The facility's policy on managing falls directed staff to implement a resident-centered fall prevention plan, which was not followed in this case, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Branch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parmly On The Lake Llc | 11.7 mi | ★★★★★ | 1 | 0 |
| The Estates At Rush City Llc | 12.4 mi | ★★★★★ | 7 | 0 |
| Meadows On Fairview | 12.8 mi | ★★★★★ | 1 | 0 |
| Gracepointe Crossing Gables | 12.8 mi | ★★★★★ | 9 | 0 |
| Birchwood Health Care Center | 15.2 mi | ★★★★★ | 4 | 1 |
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