North Woods Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 11, 2024

  Based on observation, interview and record review, the facility failed to ensure Resident B was free from staff-to-resident physical abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident B sustaining 14 severe first-degree burns (a first-degree burn affects the outer layer of skin. Burn sites were red, painful, and dry without blisters) on an ear, a lip, the neck, the upper back, the breasts, the abdomen, the bilateral thighs, the bilateral buttocks, and the perineal area. Finding includes: The immediate jeopardy began on January 6, 2024, when it was identified the resident had 14 burns that were caused from a hair dryer. […]

• Actual harm, isolatedF689Jan 25, 2022

  Based on interview and record review, the facility failed to transfer a resident using the ordered mechanical lift and with the assist of two persons for 1 of 3 residents reviewed for accidents (Resident B). Resident B sustained a knee fracture and had to have surgery to repair the fracture. Finding includes: During an interview, on 1/25/2022 at 12:52 p.m., Resident B indicated a couple of weeks ago he was getting a shower and there was only one staff to help him. He slid down the bed and his legs went behind him. They probably should have had two staff since there was usually two staff assisting him. He injured his left knee from the fall and just had surgery on it a few days ago. The record for Resident B was reviewed on 1/25/2022 at 12:23 p.m. […]

• Actual harm, isolatedF689Jan 29, 2021

  Based on interview and record review, the facility failed to ensure facility staff transferred a resident appropriately while following the resident's care plan and physician's orders [REDACTED]. This resulted in harm when Resident E experienced left leg pain and experienced a left distal femoral fracture. Finding includes: An Indiana State Department of Health Survey Report, dated 12/16/2020, provided by the Executive Director (ED) on 1/28/2021 at 12:15 p.m., indicated the incident involving Resident E occurred on 12/11/2020 at 7:04 p.m. The incident was reported to the ISDH (Indiana State Department of Health) portal on 12/12/2020 which indicated Resident E heard a pop on 12/11/2020, during a transfer. She also reported left knee pain on this date. […]

• No harm, potential for more than minimal, isolatedF656Mar 20, 2026

  Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 2 of 2 residents reviewed for care plans. (Resident 12 and 13)Findings include: 1. The clinical record for Resident 12 was reviewed on 3/16/26 at 1:40 p.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), traumatic brain injury, and diabetes mellitus. The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 5/2/25. There was no care plan located in Resident 12's electronic record related to post-traumatic stress disorder. […]

• No harm, potential for more than minimal, isolatedF684Mar 20, 2026

  Based on interview and record review, the facility failed to ensure blood pressures were obtained and documented prior to administering a blood pressure medication with parameter orders and to ensure a physician's order was followed according to the medication parameters for 2 of 6 residents reviewed for quality of care. (Residents 95 and 69)Findings Include: 1. The clinical record for Resident 95 was reviewed on 3/17/26 at 10:43 a.m. The diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, and Parkinson's disease.A care plan, dated 5/29/24, indicated Resident 95 was at risk for ineffective tissue perfusion related to high blood pressure. […]