Northwestern Healthcare Center

In the surveyor’s words

From the most serious findings on record at Northwestern Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF805May 7, 2024

  Based on observation, closed medical record review, review of an emergency medical services run report, review of facility witness statements, review of the diet guide sheet and recipes, review of the facility's diet manual, review of employee disciplinary action and interviews, the facility failed to ensure residents with physician orders for mechanically altered diets were provided the correct texture food items to prevent choking and to meet their individual needs. This resulted in Immediate Jeopardy and actual harm/death on [DATE] during the dinner meal when Resident #91, who was ordered a Dysphagia Advanced diet, was edentulous and care planned for oral problems, was served a broccoli salad; the resident was subsequently found unconscious, required cardiopulmonary resuscitation (CPR)… […]

• Immediate jeopardy, isolatedF600Aug 27, 2025

  Based on closed medical record review, staff interviews, interviews with family, family friend, and home health aide, review of Emergency Medical Services (EMS) run report and call transcripts, review of the facility's Self-Reported Incident (SRI) and investigation, and review of facility policies, the facility failed to prevent an incident of neglect involving Resident #87. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 11:30 P.M. when Resident #87 complained of chest pain to Certified Nursing Assistant (CNA) #609 who reported the change to Registered Nurse (RN) #422. RN #422 then failed to timely identify and obtain treatment for Resident #87 following an acute change in condition. […]

• Immediate jeopardy, isolatedF880Jan 18, 2022

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID- 19 line list, review of facility infection control policies, interviews with staff and residents, and medical record review, the facility failed to timely and appropriately exclude COVID-19 positive staff from working in the facility with COVID-19 negative residents. This resulted in Immediate Jeopardy on 01/04/22 when Director of Rehab (DOR) #500 tested positive for COVID-19 via a rapid test at the facility. […]

• Actual harm, isolatedF689Aug 27, 2025

  Based on closed record review, staff and family interview and policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #90 was provided adequate assistance during care to prevent a fall with major injury. Actual harm occurred 02/05/25 when Resident #90, who required substantial/maximal staff assistance with bed mobility (rolling left and right) and was dependent on staff for toileting sustained a fall from an elevated bed during the provision of care. As a result of the fall the resident suffered left and right femur fractures, a fibula fracture and a tibia fracture requiring hospitalization and medical intervention. This affected one resident (#90) of three residents reviewed for falls. […]

• Actual harm, isolatedF686Aug 26, 2024

  Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #46 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 08/20/24 when Resident #46, who was at risk for developing pressure ulcers, and was dependent on staff for bed mobility and incontinence care was identified to have new areas of in-house acquired skin impairment with no additional assessment or new treatment at that time. […]