North Woods Nursing Center

In the surveyor’s words

From the most serious findings on record at North Woods Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 13, 2021

  Based on observation, interview and record review, the facility failed to prevent neglect for 1 of 4 residents (Resident #1), resulting in Resident #1 sustaining fractures during a transfer. Findings include: A review of the facility's Identification of Abuse Policy and Procedure, revised 3/19, revealed, Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. […]

• Actual harm, isolatedF656May 13, 2021

  Based on interview and record review, the facility failed to implement the care plan prior to a bed-to-wheelchair transfer for 1 of 4 residents (Resident #1), resulting in a major injury that required surgical intervention. Findings include: A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, Resident 1's Admission Record revealed Resident #1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689May 13, 2021

  Based on interview and record review, the facility failed to provide adequate supervision and assistance for 1 of 4 residents (Resident #1), resulting in major injuries (fractures) requiring surgical intervention. Findings include: A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, Resident 1's Admission Record revealed Resident #1 had multiple diagnoses that included a displaced fracture of the left femur (leg bone), a nondisplaced fracture of the upper left humerus (arm bone), [CONDITION(S)] in both eyes, [CONDITION(S)] in both eyes, [CONDITION(S)] (an eye disease that causes blindness) in both eyes, bone density and structural disorders, arthritis, and… […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2026

  Based on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected.Findings:During an interview on 04/08/2026 at 11:37 AM, Director of Nursing (DON) reported that Infection Control Preventionist (ICP) A was off on 4/8/26 and she would review the Infection Control Program in her place. DON reported that when a facility employee called off the employee answering the phone would complete the Call off Notice form. DON confirmed that it did not need to be a licensed nurse to complete the form. […]

• No harm, potential for more than minimal, widespreadF880Feb 9, 2023

  Based on observation, interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses and failed to ensure appropriate hand hygiene (washing with soap and water) was employed for residents in contact precautions while under investigation for an unknown gastrointestinal illness, resulting in the potential for cross contamination and spread of disease-causing pathogens amongst residents and staff. Findings: Review of the facility GI (gastrointestinal) Outbreak timeline revealed, on 1/21/23 3 residents residing on the same wing were noted to develop GI related symptoms including nausea, vomiting and loose stools. This occurred following a single case on 1/18/23 with matching symptomology on the same wing. […]