Northwood Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Northwood Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 20, 2024

  Based on medical record review, observation, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure staff provided adequate supervision and intervention to prevent Resident #01, who had impaired cognition, was at risk for elopement, was housed on a secured memory care unit and who had a history of eloping from his bedroom window, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and/or injury when the resident was displaying a change of condition and was observed pacing near the nurse's station and the resident was noted to be observing Licensed Practical Nurse (LPN) #110 closely. […]

• Immediate jeopardy, isolatedF689Nov 21, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. […]

• Actual harm, isolatedF695Jun 26, 2023

  Based on medical record review, staff interview, review of the outside provider cardiologist notes, and policy review, the facility failed to ensure ordered oxygen was applied prior to transporting a resident, who required continuous oxygen, to an outside appointment. This resulted in Actual Harm when Resident #01 was sent to an outside provider appointment without ordered continuous oxygen, suffered hypoxemia (low oxygen levels in the blood), difficulty breathing and required supplemental oxygen prior to the resident being transported back to the facility. This affected one resident (#01) out of three residents reviewed who required oxygen. The census was 80. Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jun 22, 2026

  Based on observation, staff interviews, and policy review, the facility failed to store, prepare, and serve food in a safe and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 69. Observation 06/14/26 at 8:58 A.M. of the walk in cooler revealed lemonade that was undated, chicken salad with a discard date of 06/11/26, and coleslaw with a discard date of 05/26/26. Interview on 06/14/26 at 8:59 A.M. with Dietary Supervisor (DS)#273 verified the lemonade did not have a date and that the chicken salad and coleslaw should have been discarded. Observation on 06/14/26 at 9:01 A.M. revealed a can of shasta cola stored under raw meats of the walk in cooler. […]

• No harm, potential for more than minimal, widespreadF925Jun 22, 2026

  Based on observation, staff interview, and policy review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents residing in the facility. The facility census was 69.Observation on 06/14/26 at 8:56 A.M. revealed several gnats flying around near the dish machine. Interview on 06/14/26 at 9:25 A.M. with Dietary Supervisor #273 verified they have been having a problem with gnats in the dish washing area and he was planning to have the pest control company come out to treat the area. Review of the pest control reports since 02/19/26 revealed fly activity was observed in the kitchen on 02/19/26, 04/10/26, and 06/02/26. […]