Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Northwoods Lodge during CMS and state inspections, most recent first.
Failure to provide required transfer/discharge and bed-hold documentation. The facility did not give written notice to residents or representatives, did not notify the Ombudsman, and did not document that required info was sent to the receiving provider for multiple residents transferred to acute care or discharged AMA. Staff reported bed-hold info was given verbally and transfer/discharge forms were not completed for all discharges.
The facility failed to document COVID-19 vaccine education for several residents and failed to annually screen, educate, offer, and record staff acceptance or declination of the vaccine. Records for multiple residents showed no evidence that risks, benefits, and potential side effects were reviewed with the resident or representative, and leadership confirmed staff vaccination status was not formally tracked.
The facility failed to develop and implement individualized care plans for multiple residents. One resident’s anticoagulant plan listed the wrong antidote, another resident’s constipation and GI monitoring needs were not included in the care plan, and a resident with HF and renal insufficiency had conflicting weight-monitoring instructions. Two residents did not receive showers as scheduled, and an activities care plan for another resident was entered weeks after admission.
A facility failed to consistently provide scheduled showers for two residents whose care plans called for showers 3 times weekly, with one resident going 9 days and another 14 days without documented bathing. The facility also failed to provide timely meal assistance to a dependent resident with severe protein malnutrition, R-sided paralysis from a stroke, and dysphagia; the resident did not receive breakfast during tray pass, and the assigned CNA was unaware the resident needed feeding assistance until the tray was delivered about 2 hours later.
Failure to follow bowel care and weight monitoring orders: one resident with constipation had a PRN bowel regimen ordered, but no BM was documented for 4 days and there was no documented abdominal/bowel assessment or timely PRN bowel med administration. Another resident with HF on a diuretic had daily wt orders and care plan thresholds for reporting wt changes, but large wt variances were documented without evidence the provider was notified.
Failure to maintain fall safety measures for a dependent resident with stroke-related paralysis, severe malnutrition, and dysphagia led to repeated unwitnessed non-injury falls. The resident’s bed alarm was not on and the bed was not in the lowest position during one fall, and later observations showed only thin concentrator floor mats at the bedside instead of a fall mat; the DON stated a fall mat was not in place because maintenance could not find one.
PRN pain meds were given without documented NPI use for one resident with pain orders and another cognitively intact resident with pain orders, and oxycodone was also administered outside the ordered pain range. In addition, two residents with cardiac/heart failure-related med orders received eplerenone, torsemide, or metoprolol despite BP readings below the prescribed hold parameters. The DON and Administrator acknowledged the meds were given outside the ordered parameters.
The facility failed to keep complete and accurate records for two residents. One resident with dementia and dependence for bathing had repeated missed showers documented as “Activity Did not Occur” instead of refusals, and several required refusal forms were missing. Another cognitively intact resident said no one had talked with them about activities, and the activity staff member could not find documentation of any interactions despite stating she routinely offered activities and documented contacts in progress notes.
Two residents did not receive PT and OT services as outlined in their care plans due to missed sessions, delayed initiation of therapy, and limited weekend staffing. One resident experienced delays in brace management, and another left the facility against medical advice after filing a grievance about insufficient therapy services. Staff confirmed that absences and limited coverage contributed to the missed treatments.
A resident with severe cognitive impairment and high risk for pressure ulcers developed avoidable full-thickness wounds due to the facility's failure to implement adequate preventive measures and timely treatment. Despite initial assessments indicating high risk, the care plan lacked necessary interventions, and documentation was inconsistent, leading to hospitalization and surgical intervention.
The facility failed to properly monitor and maintain IV access devices for two residents. One resident with a midline catheter did not have documented measurements or assessments, and another with a PICC line lacked documentation of required measurements. These omissions risked negative health outcomes.
The facility failed to properly assess and document the use of mobility bars for three residents, leading to a deficiency in physical restraint use. A resident was unable to use the bars effectively due to limited motion, and the EHR lacked necessary documentation for consent, orders, and assessments. Staff acknowledged the oversight, which placed residents at risk of harm or entrapment.
The facility failed to maintain food safety and sanitation standards, with missing temperature logs, expired and moldy food items, and uncovered food during transportation. Staff interviews revealed a lack of adherence to protocols, placing residents at risk of foodborne illness.
The facility failed to implement proper infection control measures, including TBPs for AGPs, EBPs for residents with wounds or devices, and contact precautions. Additionally, the Legionella Water Management Program was outdated, and sharps containers were not replaced when full, increasing the risk of infection and cross-contamination.
The facility's antibiotic stewardship program failed to maintain accurate documentation for three residents, leading to inappropriate antibiotic use. A resident was prescribed antibiotics without a necessary culture, another had incorrect symptom onset dates and missing culture information, and a third lacked documentation of symptoms and culture results. Staff acknowledged these discrepancies and the failure to meet McGeer's Criteria.
The facility failed to conduct care conferences for several residents, including those who were cognitively intact and those with impairments. Residents and their representatives were not given the opportunity to participate in care planning, leading to a lack of involvement in their long-term care needs.
A resident who was cognitively intact and required assistance with bathing was not provided showers as per their preference, despite being scheduled for them. The facility's inability to accommodate the resident's mobility needs with a Hoyer lift led to the resident receiving bed baths instead. The administrator confirmed that the resident should have received showers if they could be transferred to a shower chair.
The facility failed to provide written transfer/discharge notices to two residents during their hospitalization. One resident, who was cognitively intact, and another who was moderately cognitively impaired, were transferred without documentation of the required notices. Staff members acknowledged the oversight, and the absence of these notices placed the residents and their representatives at risk of not making informed decisions.
The facility failed to provide written bed hold notices during hospital transfers for two residents, one moderately cognitively impaired and the other cognitively intact. Staff interviews confirmed that the bed hold policy was not followed during transfers, and the facility's administrator acknowledged the oversight.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident requiring oral suctioning and NPO status. The plan lacked instructions for AGP precautions and oral care, which were acknowledged as necessary by the Resident Care Manager.
A facility failed to implement a comprehensive care plan for a resident with decreased upper extremity function and moderate cognitive impairment. The care plan lacked specific guidance on meal assistance, leading to the resident being unable to open food items and consume meals. Staff confirmed the care plan did not address the resident's cubital tunnel syndrome, affecting hand function, which was noted in hospital records.
A facility failed to re-assess and revise the care plan for a resident with fractures and diabetes, leading to inadequate skin care and bathing services. The care plan lacked specific instructions for interventions, and observations showed non-compliance with care directives. Additionally, the resident's urinary tract infection was not treated with antibiotics as required. Staff interviews revealed inconsistencies in understanding the resident's care needs, placing the resident at risk for skin impairment and diminished quality of life.
The facility failed to meet professional standards of practice for four residents. A resident refused multiple doses of a prescribed laxative without provider notification. Another resident received morphine sulfate outside the ordered pain parameters. A third resident's midline catheter lacked proper maintenance documentation. Lastly, a resident's partial albuterol dose was incorrectly documented as a full dose, and the provider was not notified.
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. One resident experienced chronic constipation due to long-term opioid use, with improper medication administration and lack of non-pharmacological interventions. Another resident had orders for PRN medications but experienced multiple days without bowel movements, with no interventions documented or administered.
A facility failed to follow safety precautions for enteral feeding for a resident with Inclusion Body Myositis and dysphagia. The resident reported increased GI upset and reflux due to inconsistent checks of enteral tube placement and gastric residuals by nurses. An RN was observed not performing these checks before administering a bolus feed, contrary to facility policy and the resident's care plan.
The facility failed to obtain physician orders for respiratory care for two residents, leading to potential risks. A resident using oxygen therapy had no documented physician's order, and another resident with a CPAP machine had no specific settings known by staff. The administrator acknowledged the oversight in obtaining necessary orders.
A resident with a preference against beef continued to receive beef meals despite multiple requests for substitutions. The facility's dietary staff acknowledged the oversight, as the resident's preferences were not properly updated in the kitchen records, leading to meal dissatisfaction.
A resident with severe cognitive impairment and a history of falls suffered a hip fracture due to inadequate supervision and inconsistent implementation of safety measures. Staffing shortages and a room change further contributed to the incident. Another resident was found outside the facility, highlighting a lack of proper monitoring and documentation.
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. A resident with severe cognitive impairment experienced a fall due to inadequate supervision and environmental hazards. Another resident was found in the parking lot, indicating a lapse in supervision, while a third resident reported rough treatment by male CNAs without proper investigation. A fourth resident's fall was not thoroughly investigated to determine the root cause.
The facility did not ensure timely treatment and care for residents with a history of falls and cognitive impairment. Following an unwitnessed fall, one resident experienced a significant change in cognition and status, showing signs of confusion, pain, and decreased oral intake. There was a delay in provider notification and inadequate neurological assessments, leading to an emergency hospital transfer with multiple fractures and severe sepsis. Similarly, two other residents at risk for falls did not receive consistent neurological assessments post-fall, with delays and incomplete documentation. Staff interviews revealed discrepancies in neuro check completion and communication with providers, despite existing facility policies.
Failure to Provide Required Transfer, Discharge, and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required written notification and documentation related to hospital transfers and discharges for four sampled residents. For Resident 34, who was admitted with diagnoses including a left calf ulcer, heart failure, and muscle weakness and was able to make needs known, the record showed a hospitalization and readmission, but there was no documentation that a bed hold was offered, that a completed transfer/discharge form was prepared, or that the required information was provided to the hospital at the time of transfer. For Resident 68, who was admitted with diabetes and COPD and later had a resident-initiated discharge against medical advice, the transfer/discharge form was incomplete, was not provided to the resident, and the Ombudsman was not notified. For Residents 18 and 66, both of whom had discharge MDS records showing transfer to acute care with return anticipated, the EHRs contained no documentation that staff provided written notice to the resident and/or representative, conveyed the minimum required information to the receiving provider, or notified the Ombudsman. Staff interviews confirmed that the facility was giving only verbal bed-hold information, was not completing transfer/discharge forms for all discharges including AMA departures, and could not locate documentation showing what information was sent with the residents or that written notices were provided.
Failure to Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to ensure residents and/or their resident representatives were provided education about the COVID-19 vaccine, including the risks, benefits, and potential side effects, for 4 of 5 sampled residents reviewed for COVID-19 immunizations. Resident 16, Resident 2, Resident 27, and Resident 54 each had no documentation in the medical record showing that education had been provided to the resident and/or representative before the vaccine was offered. The facility policy required that residents receive education before the vaccine was offered and that the medical record include documentation of the education, the date it occurred, and the name of the individual who received it. The facility also failed to annually screen staff, offer the COVID-19 vaccine or provide information on where it could be obtained, and document whether staff accepted or declined the vaccine. The ADON stated she was not involved in the staff vaccination process, and the Administrator stated staff were discussed in All-Staff meetings and vaccine information was reviewed, but there was no documentation that staff were annually screened, educated, offered the vaccine, or that their acceptance or declination was recorded. The Administrator confirmed there was no annual record kept of staff vaccination status, and the process was not formalized.
Incomplete and inaccurate care plans for multiple residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 5 of 17 sampled residents whose care plans were reviewed. The deficiencies involved care planning for constipation, psychotropic medication-related target behaviors, activities, weights monitoring, and other individualized needs. The report states that the failures placed residents at risk for unidentified and/or unmet care needs and potential negative health outcomes. For Resident 16, the resident was receiving Eliquis twice daily for atrial fibrillation, but the anticoagulant care plan incorrectly documented Vitamin K as the antidote and directed staff to have it available for emergencies. The manufacturer’s insert reviewed by surveyors identified Andexxa as the only recognized antidote to apixaban. The Administrator confirmed the care plan was inaccurate. For Resident 69, the resident was cognitively impaired and had an active diagnosis of constipation, but the altered elimination care plan did not address constipation or include the daily GI assessment and monitoring documented in skilled nursing notes. For Resident 74, care plans contained conflicting weight-gain notification thresholds between heart failure and renal insufficiency plans, and the bathing plan calling for showers three times weekly was not implemented as scheduled. For Resident 72, the bathing plan also called for showers three times weekly, but the bathing record showed showers were offered or provided on only two of six scheduled shower days. For Resident 2, the activities care plan was entered five weeks after admission, despite an activities evaluation having been completed earlier and the resident stating they had not been approached about activities.
Failure to Provide Scheduled Bathing and Timely Meal Assistance
Penalty
Summary
The facility failed to consistently offer or provide showers for two residents whose care plans specified showers three times a week on evening shift. One resident was moderately cognitively impaired and had bathing marked as very important on the admission MDS; after a shower on 03/04/2026, there was no documentation that bathing was offered or provided again until 03/13/2026, nine days later. The administrator confirmed there was no documentation that bathing was offered or provided during that interval and that staff failed to provide bathing in accordance with the resident's plan of care. A second resident was cognitively intact and also had bathing marked as very important, with a care plan for showers three times weekly on evening shift. After a shower on 02/24/2026, there was no documentation that bathing was offered or provided again until 03/10/2026, 14 days later. The administrator confirmed there was no documentation of bathing being offered or provided during that period and that staff failed to provide bathing in accordance with the resident's plan of care. In addition, a dependent resident with severe protein malnutrition, right-sided paralysis from a stroke, and dysphagia did not receive timely meal assistance; the care plan directed staff to alternate small bites and sips, use a teaspoon for eating, and not use straws, but during breakfast tray pass the resident was found in bed in a gown and stated they did not receive breakfast. The assigned CNA was unaware the resident had not received breakfast or required feeding assistance, stated there was no meal tray on the cart for the resident, and the resident did not receive the breakfast tray until about two hours after the initial tray pass.
Failure to Follow Bowel Care and Weight Monitoring Orders
Penalty
Summary
The facility failed to provide necessary bowel care for Resident 69, who was admitted with cognitive impairment and an active diagnosis of constipation. The resident had physician orders for a stepwise PRN bowel regimen beginning with Miralax, followed by bisacodyl, higher-dose bisacodyl, and then a mineral oil enema if needed, with instructions to notify the MD/NP if constipation persisted for 4 days or more. The bowel record showed no documented bowel movement for 4 days, but the March 2026 MAR/TAR showed PRN bowel medication was not administered until several days later. The Daily Skilled Nursing Note Summary documented daily assessment and monitoring of GI function, but there were no abdominal or bowel assessments documented, and the Administrator stated there was no documentation showing staff performed an abdominal/bowel assessment or administered PRN bowel medication when the resident went without a BM for four consecutive days. The facility also failed to obtain and evaluate daily weights and notify the provider of significant weight variances for Resident 74, who was cognitively intact and had heart failure and was receiving a diuretic for chronic heart failure. The resident had orders for daily weights, and care plans directed staff to monitor edema and report weight gain over 2 lbs in a day, as well as report weight increases greater than 3 lbs in a day or greater than 5 lbs in a week. The record showed weights of 344.9 lbs, then 352.2 lbs the next day, followed by 352.7 lbs, 339 lbs the next day, 320.8 lbs, and then 336.2 lbs, with no documentation that the provider was notified of the weight variances. When asked, the Administrator stated there was no documentation showing the provider was notified of the resident's weight variances.
Failure to Maintain Fall Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment related to falls for one sampled resident who was admitted with severe protein malnutrition, right-sided paralysis due to a stroke, and dysphagia, and who was dependent on staff for all activities of daily living. The resident had an unwitnessed non-injury fall on 02/26/2026, and the incident report documented that a fall mat, the bed in the lowest position, and a bed alarm were in place at that time, with no new interventions or corrective measures documented afterward. The resident had another unwitnessed non-injury fall on 03/03/2026 and was found lying on the floor next to the bed. The incident report documented that the bed alarm was not on and the bed was not in the lowest position at the time of the fall. Observations later showed two small thin mats at the bedside, which maintenance identified as concentrator floor mats used for oxygen tanks rather than a fall mat. The DON stated that a fall mat was not in place because maintenance could not find one, and that central supply should have been notified to order it.
PRN pain medications and ordered hold parameters were not followed
Penalty
Summary
The facility failed to provide non-pharmacological interventions prior to administering PRN pain medications for four residents. Resident 30, who was admitted with diagnoses including high blood pressure, depression, and anxiety and was able to make needs known, had an order for acetaminophen every four hours as needed for pain and a separate order to offer multiple non-pharmaceutical interventions before PRN medication use. The March 2026 MAR showed acetaminophen was given on multiple dates, but there was no documentation that any non-pharmacological interventions were offered or provided before the medication was administered. Resident 2, who was cognitively intact, had orders for acetaminophen every 6 hours as needed for pain and oxycodone every 8 hours as needed for pain rated 6-10/10, along with an order to document non-pharmacological interventions for lower back or bilateral leg pain. Review of the MAR showed no non-pharmacological interventions had been attempted, even though acetaminophen was administered 13 times and oxycodone 15 times during the review period with documentation that interventions had been attempted. The MAR also showed oxycodone was given twice when the resident reported pain as 5/10, which was outside the ordered parameters. Resident 74 and Resident 5 also received medications outside of ordered parameters. Resident 74, who had heart failure and hypertension and received diuretics, had orders for eplerenone and torsemide to be held if systolic blood pressure was less than 110, yet both medications were administered on occasions when blood pressure readings were below that threshold. Resident 5, who had heart failure and hypertension and received diuretic medication during the assessment period, had an order for metoprolol with hold parameters for systolic blood pressure less than 110 or pulse less than 60, but the MAR showed metoprolol was administered on multiple occasions when blood pressure was below the ordered limit.
Incomplete and inaccurate resident records for bathing refusals and activity interactions
Penalty
Summary
The facility failed to maintain complete and accurate records for 2 residents reviewed for record accuracy. For Resident 54, who was admitted with dementia and was documented on the admission MDS as moderately cognitively impaired and dependent on others for showering/bathing, the shower record showed a provider order for showers on Monday, Wednesday, and Friday evenings with instructions to document whether a shower was given and, if not, to complete a refusal form and progress note. Review of the shower record from 02/22/2026 through 03/11/2026 showed the resident had not had a shower since 02/25/2026, but multiple missed showers were documented as “Activity Did not Occur” rather than as refusals, and the record did not show that the resident was offered and refused those showers. Interviews with CNA staff and nursing leadership showed the facility expected staff to reapproach a resident who refused care, notify the nurse, document the refusal in the EHR, and complete a refusal form. The refusal binder contained only two shower refusal forms for Resident 54, while additional refusal forms were missing for several missed showers. Staff also stated that the resident had been refusing care, but the documentation used for several missed showers indicated the shower did not occur rather than that it was refused. The DON stated the documentation was incorrect and that the resident had behaviors and dementia, but also acknowledged she had not met with the resident to determine why showers were being refused. For Resident 2, who was cognitively intact, the resident stated they watched television for activities and were not sure what other activities were offered, and said no one from activities had talked with them about participating. The activity professional stated she offered multiple activities, posted calendars, and would go into residents’ rooms, and said she would document resident interactions in progress notes. However, when asked to find documentation of interactions with Resident 2 since admission, she was unable to locate any. The DON stated she would expect documentation of interactions over the course of more than a month, but none was found in the record.
Failure to Provide Scheduled PT and OT Services per Care Plan
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically Physical Therapy (PT) and Occupational Therapy (OT), as outlined in the care plans for two residents. One resident, admitted with fractures to the left humerus and hip, was scheduled to receive OT five times per week but only received four sessions over eight days. This resident also experienced delays in having a hinged elbow brace removed due to lack of available therapists, despite a physician's order allowing for its removal during the day. Nursing staff did not remove the brace, stating they were not comfortable doing so without therapy staff present, even though the Rehabilitation Director later confirmed they could have performed the task. Another resident, admitted with hypercalcemia and functional decline, was to receive PT six times per week but only received five sessions over eleven days, with services starting three days after admission. This resident reported dissatisfaction with the lack of therapy services, submitted a grievance, and ultimately discharged against medical advice. Staff interviews confirmed that therapy sessions were missed due to staff callouts and limited weekend coverage, impacting the delivery of care as planned.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate measures to prevent the development of avoidable pressure ulcers and to properly assess, monitor, and obtain timely treatment orders for a resident. The resident, who was admitted with conditions including blastocystitis, weakness, and polyneuropathy, was severely cognitively impaired and required extensive assistance for positioning and transfers. Initial assessments noted redness on the buttocks, but there was no documentation on whether the redness was blanchable, and the care plan lacked identified skin impairment risks or interventions. Despite a high-risk Braden score, the facility's documentation and interventions were insufficient. Nursing progress notes initially recorded redness and an open area on the resident's buttocks, but subsequent notes failed to consistently document skin-related concerns. By the time the resident was transferred to the hospital, they had developed multiple full-thickness wounds, including pressure injuries that required surgical intervention and intravenous antibiotics. The facility's failure to document detailed descriptions, staging, or measurements of the resident's wounds in the Electronic Health Record (EHR) contributed to the deficiency. Additionally, the care plan did not include necessary interventions such as pressure-reducing devices or a turning and repositioning program, which were crucial given the resident's high risk for pressure ulcers. The lack of consistent monitoring and appropriate interventions led to the resident's hospitalization and surgical treatment for pressure ulcers.
Failure to Monitor and Maintain IV Access Devices
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of intravenous (IV) access devices for two residents receiving IV therapy. For Resident 33, who was admitted with a midline catheter for IV antibiotic therapy, the facility did not document the required measurements and assessments. Specifically, there were no records of the midline external length or upper arm circumference being measured upon insertion or during weekly dressing changes. Additionally, the facility did not change the needleless injection caps weekly or assess the midline insertion site as required. Similarly, for Resident 103, who had a PICC line for IV medication, the facility did not document the arm circumference or external catheter length upon admission or during the resident's stay. Although staff signed off on changing the PICC dressing and performing measurements, there was no place provided to record these measurements, and they were not documented in the electronic health record. These omissions placed both residents at risk for potential negative health outcomes.
Deficiency in Assessment and Documentation for Mobility Bars
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of mobility bars for three residents, leading to a deficiency in the use of physical restraints. Resident 103, who was cognitively intact, was observed with bed mobility bars but was unable to effectively use them due to limited motion. The facility's Electronic Health Record (EHR) lacked documentation for consent, orders, risk and benefits assessments, or care plan information for the mobility bars. Staff Z, the Rehabilitation Director, acknowledged that the necessary assessments and consents were not completed at the time of installation, and no assessment was provided to document Resident 103's ability to use the bedrails. Similarly, Residents 8 and 33 were observed using mobility bars without proper documentation in their EHRs, including orders, care plans, assessments, or consents. Staff C, the Case Manager, confirmed the absence of these documents and acknowledged the need for assessments by the therapy department. The facility's administrator, Staff A, also recognized the lack of necessary documentation and assessments, which did not meet the facility's expectations. This oversight placed residents at risk of accidents, harm, or entrapment related to the use of mobility bars.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and service, which placed residents at risk of foodborne illness and unsanitary conditions. Observations revealed missing entries in the food storage and dishwasher temperature logs, indicating a lack of consistent monitoring. Expired food items, such as Worcestershire sauce and cooking wine, were found in the kitchen, and a moldy container of tartar sauce was observed in the walk-in refrigerator. Additionally, uncovered foods were transported to residents' rooms and dining areas, increasing the risk of contamination. Staff interviews highlighted a lack of awareness and adherence to proper food safety protocols. The Dietary Manager acknowledged the missing log entries and the presence of expired and moldy food items, admitting that these should have been addressed. Furthermore, the Dietary Manager admitted to not covering certain food items during transportation, which could lead to contamination. An incident involving a dietary aide using a non-sanitized pen after it was dropped on the floor further demonstrated lapses in maintaining sanitary conditions.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to consistently implement transmission-based precautions (TBPs) for residents undergoing aerosol-generating procedures (AGPs). For Resident 105, who was on continuous AGP for suctioning, there was no indication on the AGP sign outside the room about the start or end of the procedure. Staff members entered the room without appropriate protective equipment, such as N-95 masks and eye protection. Similarly, for Resident 40, the AGP sign lacked necessary information, and staff entered the room without proper protective gear, unaware of the CPAP usage. Resident 33, who used a CPAP machine overnight, also had no AGP signage outside their room, leading to staff being uninformed about the precautions needed. The facility also failed to implement Enhanced Barrier Precautions (EBPs) for residents with wounds or indwelling medical devices. Resident 17, who had a leg wound, did not have EBP signage outside their room, and staff performed wound care without wearing gowns or practicing proper hand hygiene. Resident 33, who had a urinary catheter, IV, and drain, also lacked EBP signage, resulting in staff not wearing gowns during care. This lack of signage and protective measures increased the risk of cross-contamination and infection. Additionally, the facility's Legionella Water Management Program (LWMP) was outdated and did not meet current industry standards. The program lacked a comprehensive team, and the facility did not actively identify or manage hazardous conditions for Legionella growth. The LWMP diagram was incomplete, and there was no process for monitoring empty rooms or flushing faucets. Furthermore, sharps containers in several rooms were observed to be full, posing a risk of injury and infection. Staff failed to address the full containers promptly, despite being notified of the issue.
Inaccurate Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete antibiotic line listing as part of its antibiotic stewardship program, affecting three residents. For Resident 30, the facility prescribed Macrobid for a urinary tract infection without obtaining a necessary urine culture to confirm the presence of an organism susceptible to the antibiotic. The antibiotic line listing inaccurately recorded symptoms and culture dates, and the symptoms listed were inconsistent with the resident's condition, as they had a urinary catheter in place. Staff A admitted that the McGeer's Criteria were not met, and the provider was not notified of this discrepancy. Resident 354's antibiotic line listing contained errors, including incorrect symptom onset dates and missing culture information. The resident was prescribed antibiotics without documented symptoms or culture results to justify the treatment. Staff A acknowledged that the resident did not meet McGeer's Criteria and that the line listing should have included symptoms related to pneumonia, which were absent. For Resident 355, the antibiotic line listing lacked documentation of symptoms, culture results, and stop dates for the antibiotics. The resident was on antibiotics until discharge, but this information was not updated in the line listing. Staff A confirmed that without a culture, it was impossible to determine the organism's susceptibility to the antibiotic, and there was no documentation of a conversation with the provider when McGeer's Criteria were not met.
Failure to Conduct Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, which is a critical component of person-centered care planning. This deficiency was identified for five out of six sampled residents. Resident 21, who was cognitively intact, reported not having a care conference since admission, and the facility's records confirmed this absence. Similarly, Resident 156, who was moderately cognitively impaired, had a care conference scheduled but it was canceled without documentation of the rationale. Resident 154, also cognitively intact, was not contacted to set up a care conference despite expressing interest in discharge planning. Resident 40, with moderate cognitive impairment, requested a care conference, but it was not scheduled. Resident 25, who was severely cognitively impaired, had a representative who had to reach out to the case worker to understand the discharge plan, as no care conference had been held. The facility's administrator acknowledged these oversights, indicating that the lack of care conferences did not meet the facility's expectations. These failures placed residents at risk of a diminished quality of life by not involving them in their long-term care planning.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 103, who was cognitively intact and required assistance with bathing and transfer. Despite being scheduled to receive showers on specific days, Resident 103 was given bed baths instead. The resident expressed a desire for showers but was informed that due to mobility issues and the inability of the Hoyer lift to fit in the shower room, they could only receive bed baths. Staff D, the Resident Care Manager, explained that residents who required a Hoyer lift and could not transfer would receive bed baths. However, the facility's administrator, Staff A, stated that residents should receive showers if they could be transferred to a shower chair, aligning with their preferences. The discrepancy between the resident's preference and the facility's actions led to the deficiency, as the expectation was for Resident 103 to receive showers as per their preference.
Failure to Provide Transfer/Discharge Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written transfer/discharge notice to two residents, identified as Residents 30 and 40, during their hospitalization. Resident 30, who was cognitively intact, was transferred to the hospital without documentation of a transfer/discharge notice being offered or provided. Staff E, the Admissions Coordinator, acknowledged that the notice should have been sent with the resident at the time of transfer, but was unable to confirm if it was done. Staff A, the Administrator, confirmed that the notice should have been completed in the electronic health record system, Point Click Care, but found no evidence of its completion. Similarly, Resident 40, who was moderately cognitively impaired, was transferred to the hospital without documentation of a transfer/discharge notice. Staff G, the Resident Care Manager, was unsure if the notice was reviewed with the resident or their representative, and Staff E confirmed the absence of a transfer notice. Staff A also did not find any documentation of the notice being completed. This lack of documentation and communication placed the residents and their representatives at risk of not being able to make informed decisions about the transfers.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 40, who was moderately cognitively impaired, was transferred to the hospital and returned without any documentation in the Electronic Health Record (EHR) indicating that a bed hold notice was offered or provided. Staff interviews revealed that the bed hold policy was only addressed upon admission and not during hospital transfers, which was acknowledged as a mistake by the facility's administrator. Similarly, Resident 30, who was cognitively intact, was also transferred to the hospital and returned without a bed hold notice being documented in their EHR. The Admissions Coordinator confirmed that a bed hold notice should have been sent with the resident at the time of transfer, but it was not found. The facility's administrator confirmed that the bed hold notices should be offered during hospital transfers and acknowledged the oversight in both cases.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 105, who was reviewed for new admission. This deficiency involved the omission of critical care instructions for the resident, who was admitted with orders for oral suctioning, an aerosol-generating procedure (AGP), and an NPO (nothing by mouth) status. The baseline care plan did not identify the need for suctioning or AGP precautions, nor did it address the resident's NPO status. Additionally, there were no instructions provided to staff on how to perform oral care for the resident given their NPO status, such as using moistened toothettes or specifying who should provide the care. Staff D, the Resident Care Manager, acknowledged that these elements should have been included in the baseline care plan.
Failure to Implement Comprehensive Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident 13, who was admitted with decreased function in the upper extremities and moderate cognitive impairment. The care plan, dated 12/17/2024, identified self-care deficits and a potential nutritional risk but did not provide specific guidance on the level of assistance required during meals. This lack of detailed instructions led to Resident 13 being unable to open a protein drink and a cocoa packet during breakfast and being unable to cut a chicken breast during lunch, resulting in the resident not consuming the meals. Observations on 01/08/2025 revealed that Resident 13 struggled with meal consumption due to their inability to open food items and the call light being out of reach. Staff V, a CNA, confirmed that the task list, which is based on the care plan, did not specify the assistance needed for meals. Additionally, Staff C acknowledged that Resident 13's history of cubital tunnel syndrome, which affects hand function, was noted in hospital discharge records but was not addressed in the care plan. This oversight placed the resident at risk for decreased intake and a diminished quality of life.
Failure to Re-assess and Revise Care Plan for Resident
Penalty
Summary
The facility failed to re-assess and revise the care plan for a resident, identified as Resident 23, who was admitted with fractures of the left shoulder and hip, and type 2 diabetes with neuropathy. The care plan, dated 12/04/2024, indicated a risk for skin impairment due to surgical incision, left shoulder sling, and immobility, with interventions such as floating bilateral heels and using an arm sling. However, there were no specific directions for the ON/OFF schedule of the sling, and assistive devices were not included in the care plan. Observations revealed that the resident's heels were not floated, and foam boots were not in place, despite being signed off in the Treatment Administration Record. Additionally, the care plan did not include the foam boots, and the resident reported discomfort from their use. The care plan also failed to address the resident's urinary tract infection adequately, as no antibiotics were being administered despite the condition being noted. Furthermore, the resident expressed a desire for showers but only received bed baths, contrary to the care plan's instructions for bathing services. Staff interviews revealed confusion about the resident's bathing capabilities, with discrepancies between the care plan and staff understanding. These failures in care planning and execution placed the resident at risk for skin impairment, delayed care services, and diminished quality of life.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for four residents. Resident 105, who was admitted with severe hypoglycemia, fecal impaction, and as a Clostridium difficile carrier, refused polyethylene glycol doses multiple times over a 12-day period. Despite this pattern of refusal, there was no documentation indicating that the provider was notified, which was confirmed by the Resident Care Manager. Resident 304 had a physician's order for morphine sulfate extended release to be administered for pain levels of 6-10, but the medication was administered six times for pain levels below the ordered parameters, including a pain level of 0 on one occasion. Resident 33 received intravenous ertapenem via a midline catheter for 28 days, but there were no orders or documentation for essential midline maintenance and monitoring tasks, such as measuring the external length and upper arm circumference, changing injection caps, assessing the insertion site, or flushing the midline. Resident 49 had an order for albuterol nebulization as needed for a cough, but during an observation, the resident requested to stop the treatment early. The nurse documented a full dose instead of the partial dose given and failed to notify the provider, which was acknowledged as not meeting expectations by the Administrator/Director of Nursing Services.
Failure in Bowel Management for Two Residents
Penalty
Summary
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. Resident 45, who was admitted with a diagnosis of a wedge compression fracture and required pain medication, experienced chronic constipation due to long-term opioid use. Despite having orders for docusate sodium and senna, the resident's bowel elimination record showed multiple days without bowel movements, and both medications were improperly administered on the same day. Additionally, PRN medications were not ordered until several weeks after admission, and no non-pharmacological interventions were documented or implemented in the care plan. Similarly, Resident 8, who was cognitively intact and able to communicate needs, had orders for PRN medications including MiraLax, bisacodyl suppository, and mineral oil enema for bowel management. However, the resident's bowel record indicated several instances of three consecutive days without bowel movements, and no PRN medications were administered during these periods. Staff interviews confirmed the lack of pharmacological and non-pharmacological interventions, and the facility's expectations for bowel management were not met, as documented interventions were absent.
Failure to Follow Enteral Feeding Safety Precautions
Penalty
Summary
The facility failed to ensure safety precautions were followed prior to administering enteral nutrition for Resident 105, who was reviewed for enteral nutrition. The facility's policy required licensed staff to check enteral tube placement and gastric residuals before each feeding and medication administration. However, it was observed that these checks were not consistently performed, placing the resident at risk for adverse outcomes such as increased abdominal distention, reflux, and aspiration. Resident 105, who was cognitively intact and had a diagnosis of Inclusion Body Myositis and dysphagia, required enteral feeding to meet nutritional needs. The resident reported experiencing increased gastrointestinal upset and reflux since admission, which they attributed to the inconsistent checks of their enteral tube placement and gastric residuals by facility nurses. During an observation of Resident 105's bolus feeding, a registered nurse did not check the enteral tube placement or the resident's gastric residual prior to administering the bolus feed or flushes, as ordered. This was confirmed by the Resident Care Manager, who acknowledged that the checks should have been performed. The resident's enteral orders specified the administration of Jevity 1.5 and Osmolyte 1.5 via enteral tube at specific times, with instructions to check residuals and tube placement before feeding and medication administration. Despite these orders, the failure to adhere to the facility's policy and the resident's care plan led to the deficiency identified in the report.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the use of a continuous positive airway pressure (CPAP) machine and oxygen therapy for two residents, leading to potential risks for unmet care needs and respiratory complications. Resident 21, who was cognitively intact, was observed using a nasal cannula with an oxygen concentrator set at 2.5 liters per minute, yet there was no physician's order documented in the Electronic Health Record (EHR) for this oxygen therapy. Staff members confirmed that an order was necessary for administering oxygen, but none was found for Resident 21. Resident 40, diagnosed with Obstructive Sleep Apnea and moderately cognitively impaired, had a CPAP machine at their bedside. Although an order was placed for the CPAP machine to be used at night and during naps, the specific settings were not known by the staff because the machine was rented and preset. The facility administrator acknowledged that an order for the CPAP settings should have been placed upon admission, but it was only recently added.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of Resident 30, who was cognitively intact and had been admitted to the facility. Despite the dietitian visiting Resident 30 multiple times to document their food preferences, including a request to substitute beef with fish due to a preference against beef, the resident continued to receive meals containing beef. This was confirmed through observations and interviews, where Resident 30 expressed dissatisfaction with the meals and reported receiving beef stew and meatballs made with beef, despite their stated preferences. The dietary staff, including the Dietary Manager and Dietitian, acknowledged the oversight in not updating Resident 30's dietary preferences in the kitchen records. The Dietitian confirmed that Resident 30 had previously complained about receiving beef and should not have been served beef items. The Dietary Manager provided dietary change slips that documented Resident 30's request to replace beef with fish, yet the resident still received beef meals, indicating a failure in the communication and implementation of dietary preferences within the facility.
Inadequate Supervision and Documentation Lead to Resident Falls
Penalty
Summary
The facility failed to provide the necessary level of supervision to prevent avoidable accidents for residents, particularly for one resident who experienced a fall resulting in a hip fracture. This resident, who had severe cognitive impairment and a history of falls, was not consistently monitored as required by their care plan. The care plan specified one-to-one supervision and the use of a sensor alarm, but these interventions were not consistently implemented. On the night of the fall, staffing shortages led to inadequate supervision, and the resident's sensor alarm was not in place. The resident had been moved to a room further from the nurses' station, which reduced the ability for frequent visual checks. This move, combined with the lack of consistent one-to-one supervision, contributed to the resident's fall. The facility did not have a standard form for assessing fall risk or documenting interventions, leading to inconsistent implementation of safety measures. The staff on duty were not able to provide the required supervision due to being assigned multiple residents, including others who also required one-to-one supervision. Additionally, the facility failed to document the supervision provided to another resident who was found outside the facility, indicating a lack of proper monitoring and documentation. The facility's failure to document and implement the necessary supervision interventions placed residents at risk for injury and diminished quality of life. The lack of a comprehensive assessment and consistent intervention implementation highlights the deficiencies in the facility's approach to fall prevention and resident safety.
Inadequate Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall due to the absence of a one-to-one sitter, a wet floor, and a recent room change. The investigation did not fully evaluate these contributing factors or obtain statements from all potential witnesses, including the staff responsible for the missing bed alarm. Resident 2, with moderate cognitive impairment, was found in the facility parking lot, indicating a lapse in supervision. Despite the incident, the facility could not provide documentation of a thorough investigation. Similarly, Resident 3, who had no cognitive impairment, reported rough treatment by male CNAs, but the investigation failed to identify the staff involved or update the resident's care plan to reflect their request for no male agency staff. Resident 4, with moderate cognitive impairment, reported a fall in the bathroom, resulting in pain and bruising. The investigation did not include interviews or a summary to determine the root cause of the fall. In all cases, the facility's investigations were incomplete, lacking thorough evaluations and necessary documentation, which compromised resident safety and care quality.
Deficiency in Timely Treatment and Care Post-Fall
Penalty
Summary
The facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice, leading to a deficiency in care. In the case of Resident 1, who had a history of falls and cognitive impairment, the facility did not promptly address a significant change in cognition and status following an unwitnessed fall. Despite documented signs of confusion, pain, and decreased oral intake, there was a lack of timely provider notification and inadequate neurological assessments. This failure resulted in Resident 1 being emergently transferred to the hospital with multiple fractures and severe sepsis, indicating a lapse in monitoring and response to changes in condition. Similarly, for Resident 2 and Resident 3, both at risk for falls and cognitively impaired, the facility did not consistently perform neurological assessments following unwitnessed falls. Neuro checks were delayed, not completed at recommended intervals, and lacked proper documentation. Resident 2 reported a fall hours after it occurred, with delayed initiation of neuro checks, while Resident 3 had a significant delay of over 14 hours before neuro checks were initiated post-fall. These deficiencies in timely assessment and monitoring post-falls put residents at risk for undetected injuries, complications, and compromised quality of care. Staff interviews revealed discrepancies in the completion and documentation of neuro checks, with staff acknowledging lapses in assessment and communication with providers. Despite facility policies outlining the frequency and protocol for neurological assessments post-falls, there was a failure to consistently adhere to these guidelines, leading to gaps in care delivery and missed opportunities for early intervention. The lack of thorough and timely assessments following changes in residents' conditions highlights systemic issues in monitoring and responding to residents' needs effectively.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 863 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silverdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martha And Mary Health Service | 4.6 mi | ★★★★★ | 16 | 0 |
| Bremerton Trails Post Acute | 6.6 mi | ★★★★★ | 55 | 0 |
| Belmont Terrace | 6.7 mi | ★★★★★ | 22 | 0 |
| Port Washington Post Acute | 7.7 mi | ★★★★★ | 15 | 0 |
| Bainbridge Island Health & Rehab Center | 8 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.