Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 North Central Health Care during CMS and state inspections, most recent first.
A cognitively intact resident admitted for orthopedic aftercare reported $115 missing from their wallet. The facility initiated an investigation, searched the room, and interviewed staff who had worked on the unit during the relevant period, but did not interview other residents on the unit to determine if there were additional missing money/property concerns or trends, despite a policy requiring monitoring for such trends. During surveyor review, leadership confirmed that other residents had not been specifically interviewed as part of this investigation.
A facility failed to provide adequate supervision and keep fall interventions current for two residents with repeated falls. One resident with dementia and a recent ankle fracture had multiple unwitnessed falls, including a major fall that resulted in a femur and pelvic fracture and hospice enrollment, while several interventions such as call light reminders and monitoring were not consistently added to the care plan. Another severely cognitively impaired resident had repeated unwitnessed falls in the dining room, room, toilet area, out of bed, and from a wheelchair, but multiple interventions documented in progress notes were not reflected in the care plan for CNA access.
Failure to include residents in care conferences after MDS assessments: The facility did not document that 4 residents or their representatives were invited to, participated in, or declined care conference meetings after multiple MDS assessments. Records showed residents with diagnoses including paraplegia, dementia, chronic pain, CAD, renal insufficiency, and DM had care conferences documented inconsistently, and staff stated quarterly care conferences were not routinely offered and invitations were not consistently documented.
Uncovered clean linens were observed in the laundry area while dirty fans were blowing debris directly onto them. The facility policy required linens stored in the laundry to be on covered carts and kept away from environmental contamination. The Laundry Team Coordinator and ESM both acknowledged the linens should have been covered and the fans should not have been blowing on the clean laundry.
Failure to Provide Required Transfer and Discharge Notices The facility did not complete required written transfer, discharge, bed-hold, or ombudsman notifications for 5 of 5 residents reviewed. A resident with stroke, DM, and HF was sent to the ER by ambulance after acute SOB and low O2 sats, but no written transfer notice was in the record. Other residents transferred to the hospital had bed-hold notices signed by SW only, with no evidence the notices were given to the resident or representative, and staff acknowledged the facility was not using a written transfer form. For one resident discharged after rehab, the ombudsman was not notified.
Unsafe Hand Hygiene and Glove Use During Food Prep: A Dietary Aide was observed handling food, utensils, refrigerator handles, and equipment with contaminated gloved hands, wiping her face with gloves on, then removing gloves and not washing hands before continuing to plate food. The DA later acknowledged she did not wash her hands after glove removal or before putting on new gloves, while the DM stated staff are expected to perform hand hygiene before gloving, after glove removal, and after touching the face or contaminated surfaces.
A resident with acute respiratory failure, quadriplegia, ventilator dependence, dysphagia, and constipation had repeated episodes of respiratory distress with prolonged manual bagging, low tidal volumes, abnormal breath sounds, desaturation, and ventilator desynchrony, along with multiple days of no documented BM and abdominal bloating/distention. The record and survey observations showed that staff did not notify the physician on call during these significant changes, and RT stated there was no set parameter for when to call while manually bagging.
A resident admitted with PTSD, depression, alcohol abuse, and seizures had an inaccurate PASRR Level I screen that marked no major mental disorder despite records showing PTSD in the H&P, hospital discharge summary, and MDS. The SW confirmed PTSD should have been marked as a major mental illness and that a Level II screen was required, but no Level II was completed.
Failure to provide needed toileting and repositioning care for two residents. One resident with severe cognitive impairment and incontinence had care plan interventions for prompted repositioning and toileting, but was observed sitting in the same position for hours, later found with moisture-associated skin damage and an open/macerated buttock area, and no cream was applied after hygiene. A second resident with moderate cognitive impairment had care plan directions for dependent repositioning and toileting assistance, but was observed in bed for an extended period, with staff and the resident describing inconsistent brief changes and toileting based on staff availability.
A resident who was totally dependent, tube fed, and had diagnoses including constipation, quadriplegia, and ventilator dependence did not receive consistent bowel management or documented GI assessments with tube feeding. The record showed repeated days with no BM documented, no bowel and bladder care plan, abdominal distention, hypoactive bowel sounds, and episodes of colonic ileus with ventilator dyssynchrony. During survey observation, the resident was in respiratory distress, and RT and nursing staff linked the resident’s ventilator fighting to constipation and lack of bowel movements.
A resident with severe cognitive impairment, stroke-related one-sided paralysis, Parkinson's disease, and impaired ROM to all extremities did not receive ordered restorative care for the right hand. Surveyor observations showed the resident's fingers curled tightly with no splint in place, and review of the splint log showed the right-hand splint was not provided on 10 of 19 days. Staff interviews showed confusion about whether CNAs or nurses were responsible for ROM and splinting, and the care instructions in the resident's closet did not include the brace task.
Improper Foley Catheter Care and Hand Hygiene: A resident with an indwelling Foley catheter, severe cognitive impairment, and recent UTI/septic shock received peri care and catheter emptying with poor infection-control practices. A CNA used the same gloves throughout care, did not clean the catheter tubing, failed to sanitize hands after peri care, placed a urinal directly on the floor, and used the same alcohol wipe to clean the catheter port after emptying the bag. The CNA and DON described different expectations for catheter care and hand hygiene.
Failure to Verify G-Tube Placement Before Med Pass: An RN administered liquid meds through a resident’s G-tube after flushing with water, but did not verify tube placement or check gastric residuals first, despite facility policy requiring placement checks before each med pass. The resident was totally dependent, NPO, and receiving PEG tube feeding with orders for residual checks and re-instillation; the RN later acknowledged not realizing placement verification was required, and the Nurse Manager stated staff are trained to aspirate gastric contents before giving meds or tube feedings.
Staff did not ensure an RN had completed ventilator and suctioning training before working on a ventilator unit resident with severe respiratory and neurologic diagnoses. A CNA observed tan secretions running from the resident's mouth and chin, wiped them away, and did not report them; the RN stated she would have wanted notification but was not comfortable suctioning because she had not been trained on the unit. The RT and Nurse Manager confirmed staff are trained upon hire and annually, and that the RN had not completed the required training before her first shift on the unit.
A resident with severe cognitive impairment and on hospice care was injured during a transfer using a Hoyer lift when staff used the incorrect sling type. The resident fell, sustaining a closed head injury, and later passed away. The facility's failure to ensure the correct sling type was used led to this incident.
The facility failed to store, prepare, and distribute foods in a sanitary manner, affecting 111 residents. Cook F was observed with an uncovered mustache, and various kitchen equipment were left uncovered while not in use, contrary to the facility's policies.
The facility failed to prevent the spread of infections by not sanitizing mechanical lifts between uses, not providing hand hygiene for residents before eating, and not performing proper hand hygiene between glove changes during care.
A resident with severe cognitive impairment and behavioral issues was not adequately supervised, leading to an incident where another resident sustained injuries. The care plan, which included increased staff surveillance and a chime alarm, was not effectively implemented, resulting in a lack of supervision and increased risk to other residents.
Failure to Thoroughly Investigate Report of Missing Resident Money
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into a cognitively intact resident’s report of missing money. The resident was admitted for orthopedic aftercare and had an admission MDS BIMS score of 14/15, indicating intact cognition. On 02/13/26 at approximately 5:30 PM, the resident reported to a facility nurse that $115.00 was missing from their wallet and stated the last time they saw the money was about a week earlier. The facility initiated an investigation, notified the police, and conducted a thorough search of the resident’s room. Staff who worked on the unit between 02/06/26 and 02/13/26 were interviewed, but the missing money was not found. Despite these steps, the investigation did not include interviews with other residents on the unit to determine whether there were additional reports of missing money or property, or to identify any related concerns, risks, or trends. The facility’s policy on abuse, neglect, misappropriation, exploitation, resident-to-resident altercations, injury of unknown origin, and caregiver misconduct, last reviewed on 08/07/25, states that monitoring will include identification of any department, caregiver, and/or resident trends. On 03/17/26, the surveyor reviewed the investigation and confirmed that other residents on the unit had not been interviewed as part of this incident. During interviews on that date, the Nursing Home Administrator and Social Services staff acknowledged that residents were not specifically interviewed in connection with this investigation.
Failure to update fall interventions and provide adequate supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two sampled residents, including one resident who sustained multiple falls without a determined root cause and later suffered a major injury, and another resident whose repeated falls were not reflected in the care plan. The facility’s falls policy and procedure required fall huddles, communication of interventions to relevant staff, documentation of interventions, and updating the plan of care, but the record showed repeated gaps between fall events, progress notes, and care plan updates. One resident was admitted for short-term rehabilitation after a right ankle fracture repair and was initially assessed as high risk for falls. After an early fall in which the resident slid from a recliner, the care plan was updated with fall interventions, but later changes in mobility status and subsequent falls were not consistently reflected in the care plan. The resident fell again after ambulating to the bathroom without assistance, then later fell from bed after trying to get up to use the bathroom, and another fall occurred when the resident was found on the floor next to the bed with multiple bruises and pain to the hip. The resident was sent to the ER and was found to have a significant femur fracture and closed fracture of the pelvis, after which hospice services were elected. Surveyor interviews showed staff described interventions such as call light reminders, frequent monitoring, low bed use, and wheelchair placement, but several of these interventions were not added to the care plan, and staff acknowledged they did not know why some interventions were missing. The second resident had severe cognitive impairment and multiple unwitnessed falls in different locations, including the dining room, room, toilet area, out of bed, and from a wheelchair while putting on slippers. After several falls, progress notes documented interventions such as reminders to ask for help, signage, frequent monitoring, toileting prompts, medication review, and therapy evaluation, but multiple interventions were not added to the care plan. The report states that interventions not added to the care plan were not available for CNAs to see on the resident care profile, limiting staff access to current fall-prevention interventions for that resident.
Failure to Include Residents in Care Conferences After MDS Assessments
Penalty
Summary
The facility did not ensure each resident or their representative had the right to participate in the care planning process after each MDS assessment for 4 of 4 residents reviewed for care conferences. The facility policy stated care plans are built by the IDT with input from the resident or resident representative, and resident goals are reviewed at care conferences. However, record review showed that R6, R2, R3, and R48 had multiple MDS assessments completed without documentation that they or their representatives were invited to, participated in, or declined care conference meetings for each assessment. R6 had diagnoses including paraplegia, neuromuscular dysfunction, and malignant neoplasm of the left kidney, and an annual MDS documented a BIMS score of 10/15, indicating moderate cognitive impairment. R2 had diagnoses including cystitis, osteoarthritis, chronic pain, nutritional anemia, pressure ulcer of another site, bladder-neck obstruction, disease of intestine, reduced mobility, and insomnia. R3 had diagnoses including Alzheimer's disease, dementia, dysphagia, atrial fibrillation, anxiety disorder, adjustment disorder with depressed mood, and BPH. R48 had diagnoses including CAD, renal insufficiency, and diabetes mellitus. Interviews with the DON, MN, NHA, and SW showed the facility held care conferences with residents for annual assessments, had just started in-person care conferences, did not invite residents for quarterly care conferences, and did not consistently document when residents were invited or declined.
Uncovered Clean Laundry Exposed to Dirty Fans
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. During observation in the laundry room, surveyors found an uncovered cart of clean laundry in the clean laundry area while large fans with fuzzy, dirty debris were blowing directly onto the uncovered linens. The facility’s policy stated that linens stored in the laundry will be on covered carts and that clean linens will not be stored in areas with environmental contamination. The Laundry Team Coordinator stated the clean laundry should have been covered and that the fans were dirty and should not have been blowing directly on the clean laundry. The Environmental Services Manager also stated the clean laundry should have been covered and agreed the fans needed to be cleaned and should not have been blowing on the clean laundry.
Failure to Provide Required Transfer, Discharge, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility did not complete the required discharge and transfer notification process for 5 of 5 residents reviewed for discharge or transfer. The report states that residents R124, R6, R2, R43, and R126 did not receive the required written documentation or notification related to transfer, discharge, appeal rights, bed-hold policies, or ombudsman notification as applicable. Surveyor review and staff interviews showed that the facility was not consistently providing written transfer notices, bed-hold notices, or ombudsman notification, and staff acknowledged that the process was not being completed as required. R124 was admitted with diagnoses including stroke, diabetes, and heart failure and had moderate cognitive impairment with a BIMS score of 11 out of 15. After R124 complained of difficulty breathing, oxygen saturation dropped into the 60s, oxygen was applied, 911 was called, and the resident was sent to the emergency room by ambulance. Although family was notified, there was no written notice of transfer in the record. The Nurse Manager stated the facility had not been using a written transfer form for hospital transfers and would develop one going forward. R6 and R2 were both transferred to the hospital, and their records contained bed-hold notices signed by the Social Worker, but the notices were not signed by the residents and did not document that the notices were given to the residents or their representatives. Their records also did not document that a written reason for transfer or discharge notice was provided. R43 was transferred to the hospital, and surveyors could not find evidence that either a bed-hold notice or a notice of transfer had been provided to the resident or representative. For R126, who was discharged after completing short-term rehab and had a discharge summary signed by the resident, the facility did not notify the ombudsman of the discharge; staff stated they only notify the ombudsman for hospitalizations or emergency room visits.
Unsafe Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food was prepared and distributed. During observation on the second floor of the north wing, a Dietary Aide washed hands and put on gloves, then handled bread bags, refrigerator handles, a butter container, utensils, bread, cheese, a spatula, and the microwave surface with the same gloved hands. The aide also wiped her face with gloved hands while continuing food preparation, then removed gloves and did not wash hands before taking grilled cheese off the griddle and plating it, and later put on new gloves without washing hands. During interview, the Dietary Aide stated she had not been told she needed to change gloves after touching surfaces and then touching resident food directly, and acknowledged she did not wash her hands after removing gloves or before applying new gloves. The Dietary Manager stated staff are expected to wash hands before applying gloves, after removing gloves, and to perform hand hygiene and change gloves after touching the face or contaminated surfaces and before directly touching residents' food.
Failure to Notify Physician of Respiratory Distress and GI Changes
Penalty
Summary
The facility failed to immediately notify the physician on call of significant changes in a resident’s respiratory status and gastrointestinal status. The resident was admitted with acute respiratory failure with hypoxia, multiple sclerosis, quadriplegia, dependence on a ventilator, dysphagia, constipation, and other diagnoses, and was totally dependent on staff for all care. The resident’s care plan included respiratory monitoring, tube feeding, and constipation-related orders, but the record did not show a bowel and bladder care plan after the prior one was discontinued. Record review showed numerous episodes in which the resident required manual bagging for respiratory distress, ventilator desynchrony, low tidal volumes, diminished or abnormal breath sounds, and changes in color or oxygen saturation. These episodes included events where staff manually bagged the resident for several minutes, about 30 minutes, 45 minutes, 1 hour and 20 minutes, and other prolonged periods, with documentation of suctioning, repositioning, trach adjustments, morphine, bronchodilator treatments, and difficulty passing the suction catheter. The report states that the physician on call was not notified for these respiratory changes during the episodes described in the progress notes. The record also showed repeated days with no documented bowel movement, including multiple multi-day stretches across 2024 and 2025, and the report states the physician was not notified on those occasions. Notes also documented abdominal discomfort, bloating, and distention, including a note that the abdomen appeared bloated and another that the resident had abdominal discomfort and appeared somewhat bloated/distended during a respiratory event. During survey observation, the resident was in respiratory distress while RT F manually bagged him, alarms were sounding, and staff discussed what was happening while continuing bagging. The surveyor later interviewed RT F, who stated RT F did not notify the physician on call unless absolutely necessary and had no policy or parameters for how long to manually bag before notifying the physician. The Nurse Manager stated that significant changes should be reported within 15-30 minutes and that staff should not go that long without notifying the physician while manually bagging.
Inaccurate PASRR Screening for Resident With PTSD
Penalty
Summary
The facility did not ensure that the PASRR Level I screen for one resident with a diagnosis of PTSD was completed accurately. The resident was admitted with diagnoses including PTSD, depression, alcohol abuse, and seizures, and had a BIMS score indicating moderate cognitive impairment. The resident’s admission MDS also identified an active diagnosis of PTSD, and the resident’s history and physical and hospital discharge summary documented PTSD and depression. Despite this information, the PASRR Level I screen completed on the resident indicated “No” for a major mental disorder in Section A, Current Diagnosis, and no Level II screen was submitted for further review. The report states that federal PASRR guidance requires residents with a “Yes” response for a major mental illness on the Level I screen to be referred for a Level II screen. During interview, the SW confirmed that PTSD would be marked as a major mental illness on the PASRR Level I screen and that a Level II screen would be required for a resident admitted with PTSD. The SW also confirmed that the resident had PTSD upon admission based on the hospital discharge summary and history and physical, that the Level I screen had been completed inaccurately, and that no Level II screen had been done.
Failure to Provide Needed Toileting and Repositioning Care
Penalty
Summary
The facility did not ensure two residents were provided the necessary services to maintain personal hygiene, specifically related to toileting and repositioning. One resident had a BIMS score of 3/15 and was severely cognitively impaired, with care plan interventions for prompted repositioning and assist of 2 for toileting, but no toileting frequency was listed. The resident also had care plan problems related to altered skin integrity, frequent bowel and bladder incontinence, and use of skin and bowel/bladder standards of care. A progress note documented moisture associated skin damage to the left gluteal area and a reddened groin. Surveyor observation showed the resident sitting in the same chair and position from before breakfast until 10:19 AM, and CNA O stated the resident had only been toileted/repositioned once on the AM shift after being up before 6:00 AM on night shift. Later, at 1:53 PM, the surveyor observed CNA O and CNA P toilet the resident and noted an open/macerated area to the buttocks and a red spot comparable in size to a pencil eraser. CNA O stated cream was available for the resident's bottom, but no cream was applied after toileting hygiene was completed. Staff interviews reflected varying toileting routines, including toileting every 2 hours or around meals, but the resident's care profile did not indicate whether the resident was independent, prompted, or dependent. A second resident had a BIMS score of 9/15 and was moderately cognitively impaired. The resident's care plan called for dependent repositioning, bed mobility, and toileting assist of 2 when asleep and assist of 1 when awake, with additional care plan problems for altered skin integrity and risk for altered elimination pattern related to decreased mobility and dementia. The resident was observed in bed at 7:45 AM and still in bed at 10:54 AM. CNA P stated the resident was last changed/repositioned at 9:00 AM, and the surveyor observed the resident's room until 12:36 PM before CNAs entered to begin cares. The resident later stated staff changed the brief only when they had time, that the wait depended on who was working, and that the resident only got changed when in bed and stayed in the recliner for several hours once up.
Failure to Provide Timely Bowel Management and GI Assessment
Penalty
Summary
The facility did not provide care and treatment according to orders, resident preferences, and goals when it failed to ensure timely gastrointestinal assessment and bowel management for a resident who was totally dependent on staff for all care. The resident had multiple diagnoses including multiple sclerosis, quadriplegia, dependence on a ventilator, dysphagia, constipation, and contractures. The resident’s orders included multiple bowel-related medications and interventions, including Miralax, docusate sodium, bisacodyl suppository PRN, and rectal decompression as needed, but the record did not show a bowel and bladder care plan in place after the prior one was discontinued. Record review showed repeated periods with no bowel movement documented over multiple days across many months, and survey review noted that GI assessments were not found with tube feeding administration on several occasions. Progress notes documented abdominal distention, hypoactive bowel sounds, and episodes of ventilator desynchrony associated with bowel issues. On one occasion, an abdominal x-ray showed colonic ileus after the resident developed abdominal distention and respiratory difficulty, and the provider documented paralytic ileus with a distended abdomen and faint bowel sounds. The record also showed that the resident had loose bowel movements at times, but bowel sounds remained hypoactive and the abdomen remained distended. During survey observation, the resident was seen in respiratory distress while alarms sounded in the room. The respiratory therapist asked when the resident’s last bowel movement had occurred and stated that when the resident does not have a bowel movement for a while, the resident bears down and fights the ventilator, with these episodes becoming increasingly frequent. The nurse manager later stated that the resident should be having bowel movements every day because of tube feeding and past bowel issues affecting respiratory status, and acknowledged that the resident did not have a bowel regimen care plan in place despite being admitted with constipation issues.
Failure to Provide Ordered ROM and Right-Hand Splinting
Penalty
Summary
The facility did not ensure a resident with limited ROM received the ordered restorative treatment and services to maintain or prevent further reduction in ROM. The resident had diagnoses including stroke with one-sided paralysis, Parkinson's disease, encephalopathy, epilepsy, and COPD, and had severe cognitive impairment on the BIMS. The MDS indicated impaired ROM to all extremities and dependence on staff for all bed mobility, transfers, toileting hygiene, and eating. The care plan directed staff to provide gentle passive ROM to the right hand and apply a palm guard splint in the morning and remove it at bedtime, but the care instructions in the resident's closet did not mention hand brace application or removal. Surveyor observations from multiple spot checks and a continuous observation showed the resident in a reclining high-back wheelchair with fingers curled tight to both hands and the right hand held tight against the chest, with no brace or cloth placed in either hand and no staff attempting to apply the right-hand brace. Review of the August 2025 splint sign-out sheet showed the resident did not receive the right-hand splint for 10 of the last 19 days. Staff interviews reflected confusion about who was responsible for restorative care, with one CNA stating nurses were to complete it, an LPN stating CNAs were responsible, and other CNAs stating either CNAs or nurses could do ROM and that the splint sometimes got missed because units were switched frequently.
Improper Foley Catheter Care and Hand Hygiene
Penalty
Summary
The facility did not ensure appropriate catheter care and hand hygiene were provided for a resident with an indwelling Foley catheter. The resident had diagnoses including cystitis, bladder-neck obstruction, disease of intestine, and reduced mobility, and the MDS documented severe cognitive impairment with a BIMS score of 6/15. The resident was dependent on staff for toilet hygiene and had a urinary catheter. The resident also had a hospital admission for UTI and septic shock, and was seen by urology and placed on an antibiotic for UTI. During observation of morning care, a CNA provided peri care using the same gloves after washing the resident’s groin and penis, did not clean the urinary catheter tubing, and did not remove gloves or sanitize hands after peri care. The CNA then retrieved a urinal and alcohol wipes, placed the urinal directly on the floor, and used the same contaminated gloves to remove the catheter port from the catheter bag, wipe the port with an alcohol wipe, and empty the urine into the urinal. The CNA then used the same alcohol wipe to clean the catheter port again and returned it to the catheter bag holder. In interview, the CNA stated hand hygiene should have been performed after peri care and acknowledged a barrier should have been used under the urinal on the floor, while also stating the same alcohol wipe had been used because the CNA had not been trained to use another wipe. The DON stated the expectation was hand hygiene after peri care, use of a barrier, and a clean alcohol wipe after emptying the catheter bag.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to follow standards of practice for verifying gastrostomy tube placement before medication administration for one resident who was admitted with diagnoses including acute respiratory failure with hypoxia, multiple sclerosis, quadriplegia, dysphagia, and dependence on a ventilator, and who was totally dependent on staff for all cares. The resident’s care plan directed staff to monitor tube feeding tolerance and provide tube feeding and water flushes as ordered, and physician orders included PEG tube feeding, residual gastric contents checks every 4 hours with re-instillation, NPO status, and medications to be given through the gastric tube. During observation, an RN entered the resident’s room with liquid medications, flushed the G-tube with 60 mL of water, administered the medications, and flushed again with another 60 mL of water. The surveyor did not observe the RN check tube placement or gastric residuals before giving the medications, despite the facility protocol stating that gastric tube placement must be checked before each medication administration. In interview, the RN stated that the tube was flushed before and after medications and acknowledged not realizing that verifying placement was required before administering medications. The Nurse Manager stated that nurses are trained to verify G-tube placement by aspirating gastric contents and checking residuals before administering medications or Jevity, and that the RN should have checked the resident’s residuals before giving the medications.
Staff Lacked Ventilator and Suctioning Competency
Penalty
Summary
The facility did not ensure that nursing staff had the appropriate competencies and skills to provide care for a resident on the ventilator unit, specifically because RN E had not completed ventilator and suctioning training before working on the unit. The resident involved was admitted and readmitted with diagnoses including acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, pneumonia, cerebral vascular accident with advanced brain injury, Alzheimer's disease, COPD, hypertensive heart disease with heart failure, chronic diastolic heart failure, and persistent vegetative state. The resident's respiratory care plan directed staff to maintain a patent airway, adequate ventilation, good pulmonary hygiene, oxygen saturation above 90%, and to provide suctioning as needed along with daily and PRN trach care and scheduled and PRN trach tube changes. During observation, a CNA entered the resident's room and saw tan-colored secretions running down the resident's mouth and chin while the resident was sleeping on the ventilator. The CNA wiped the resident's mouth and left without reporting the secretions to a nurse. In interview, the CNA stated CNAs are trained to suction when there are visible secretions around the lips and outside the mouth, but did not think the resident needed suctioning and did not report it. RN E stated that if the CNA had reported the secretions, RN E would have wanted to be notified, but RN E also stated that RN E would not suction the resident because RN E did not feel comfortable with suctioning and had not received training on the ventilator unit. The RT and Nurse Manager stated staff are trained upon hire and annually, and the Nurse Manager later confirmed RN E did not complete ventilator and suctioning training before working on the ventilator unit for the first shift.
Resident Injury Due to Incorrect Sling Use During Transfer
Penalty
Summary
The facility failed to ensure a resident using a Hoyer lift for transfers received adequate supervision and assistance devices, leading to a serious incident. The resident, who had severe cognitive impairment and was on hospice care due to failure to thrive, osteoporosis, and weight loss, was transferred using the incorrect sling type. The care plan had been updated to use a split leg sling due to the resident's tendency to lean forward, but staff used an hourglass sling instead. This error resulted in the resident falling from the lift, sustaining a closed head injury, and subsequently passing away. The incident occurred when a CNA, who was not familiar with the resident's updated care plan, assisted in transferring the resident from a chair to a bed. The CNA was unaware of the change in sling type, as it was not communicated in the 72-hour report. During the transfer, the resident leaned forward and fell out of the hourglass sling, hitting the right side of her face on the leg of the Hoyer lift. This fall caused a nosebleed and bruising to the eyes, forehead, and cheekbone, and the resident was later placed on bed rest and comfort measures. The facility's documentation indicates that an investigation was initiated immediately after the incident, identifying the use of the wrong sling type as the cause. The medical examiner determined the cause of death as complications from a closed head injury due to the fall. The facility's failure to ensure the correct sling type was used for the resident's transfer created a situation of immediate jeopardy, which was later addressed by the facility.
Removal Plan
- Corrective actions were immediately put into place to ensure all residents who require mechanical lift transfers have the appropriate sling type and size.
- Removed Hoyer lift from service to be checked over by Biomed before using again.
- Removed staff involved from conducting any resident transfers pending investigation.
- Immediate education provided to all staff working and education continued for all staff as they came onto their shift.
- Removed full body lift from service to be checked over by Biomed before using again.
- Education started immediately via a read and sign on PSST (position, sling, size, type) importance of walking rounds and communication.
- Implemented sling audit to be completed at each shift change during walking rounds to verify correct sling continues to be used. The audit is ongoing and will be evaluated at QAPI.
- All residents requiring a full body lift or sit to stand lift were audited to validate that the care plan and the sling in the room matched.
- Educated all staff that slings should be laundered on the unit to always ensure availability of correct slings on the units.
- Signs were placed in all soiled linens rooms reminding staff to NOT send to central laundry to ensure correct sling size always available.
- Added hooks to the back of resident room doors to store slings in an easily accessible area.
- A visual of the sling types was posted on each full body lift.
- Online education-module was assigned to all nurses and CNAs including agency staff which included lifting techniques and sling details and had acknowledgment of understanding through a post module exam. This education was completed, correcting the deficiency.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility did not store, prepare, and distribute foods in a sanitary manner, which has the potential to affect 111 residents who eat orally. During an initial tour of the kitchen, Cook F was observed with an uncovered mustache, despite the facility's policy requiring all facial hair to be covered. Both the Supervisor of Nutritional Services (SNS) G and the Director of Nutritional Services (DNS) H confirmed that the expectation is for all hair, including facial hair, to be covered in the kitchen. Cook F acknowledged the requirement but did not comply during the tour, leading to a potential risk of contamination in the food preparation area. Additionally, various pieces of kitchen equipment, including a can opener, blender, steam jacket/kettle, and robo-coup food processor, were observed uncovered while not in use. The facility's policy mandates that all equipment should be covered when not in use to prevent contamination. Both Cook F and SNS G acknowledged that not covering the equipment poses a potential contamination risk. DNS H also confirmed that all equipment in the kitchen needs to be covered when not in use, indicating a lapse in adherence to the facility's food safety protocols.
Infection Control Deficiencies
Penalty
Summary
The facility failed to properly prevent the spread of infections as evidenced by multiple deficiencies in infection control practices. Mechanical lifts were not sanitized between uses for four residents, despite facility policy requiring sanitization with Purple Super Sani-Cloth wipes or 3M 40A after each use. Observations showed that CNAs did not wipe down the lifts after transferring residents, even when residents were on Enhanced Barrier Precautions. Interviews with staff confirmed that they were aware of the policy but failed to follow it consistently. Additionally, the facility did not provide hand hygiene for six residents before eating. These residents, who were observed wandering around the dementia care wing and touching various surfaces, were served snacks without being offered hand hygiene. Interviews with the CNAs responsible for serving the snacks revealed that they did not consider hand hygiene before serving food, despite acknowledging its importance. The facility also failed to perform proper hand hygiene between glove changes during care for one resident. The resident, who had a history of sepsis and pressure ulcers, was observed receiving care from a CNA who did not perform hand hygiene after removing gloves and before donning new ones. This lapse in protocol was confirmed through interviews with the CNA and the charge nurse, who both acknowledged the expectation for hand hygiene between glove changes and after handling potentially contaminated items.
Inadequate Supervision Leading to Resident-to-Resident Incident
Penalty
Summary
The facility did not provide adequate supervision to prevent resident-to-resident incidents, specifically involving a resident with severe cognitive impairment and behavioral issues. The resident, who has a history of wandering and aggressive behavior, was found in another resident's room, leading to an incident where the other resident sustained injuries. The care plan for the resident included measures such as increased staff surveillance and the use of a chime alarm to alert staff of the resident's movements, but these measures were not effectively implemented on the night of the incident. On the night of the incident, both the RN and CNA were assisting another resident, leaving the nurse's desk unattended. During this time, the resident in question wandered into another resident's room, resulting in the other resident being found on the floor with injuries. The RN did not follow the care plan, which required staff to be present at the nurse's desk to respond to the chime alarm and to provide supervision to the wandering resident. The RN admitted that the care plan was not followed, and the lack of supervision placed other residents at risk. The Director of Nursing confirmed that the staff did not adhere to the care plan and that the resident's door chime only works if the door is closed, which may not have been the case. The facility has since ordered a motion alarm with a pager to better monitor the resident's movements and has issued a memo requiring staff to supervise the resident in the day area until the new alarm system is in place. However, these corrective actions were not in place at the time of the incident, leading to the deficiency in supervision and resident safety.
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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 Wausau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amethyst Health Of Wausau | 1.2 mi | ★★★★★ | 37 | 4 |
| Wood Aven Health And Rehabilitation | 2.8 mi | ★★★★★ | 14 | 0 |
| Wausau Manor Health Services | 3.8 mi | ★★★★★ | 12 | 0 |
| Rennes Health And Rehab Center-weston | 4.6 mi | ★★★★★ | 1 | 0 |
| Pride Tlc Therapy And Living Campus | 5.3 mi | ★★★★★ | 8 | 0 |
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