Northwoods Lodge

In the surveyor’s words

From the most serious findings on record at Northwoods Lodge, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 13, 2025

  Based on observation, interview, and record review, the facility failed to consistently implement measures to prevent development of avoidable pressure ulcers and to thoroughly assess, monitor and obtain timely treatment orders for pressure ulcers for 1 of 4 sampled residents (Resident 38) reviewed for pressure ulcers. Resident 38 experienced harm when they developed two avoidable pressure ulcers which required hospitalization for surgical intervention and intravenous (in the vein) antibiotics. Findings included . Resident 38 admitted to the facility on [DATE] with diagnoses of blastocystitis (an infection of the intestines caused by a parasite, may cause diarrhea), weakness, and polyneuropathy (damage to multiple nerves). […]

• Actual harm, isolatedF689Sep 27, 2024

  Based on observation, interview and record review, the facility failed to provide the assessed level of supervision required to ensure residents were free from avoidable accidents for 1 of 3 residents (Resident 1) reviewed for accident hazards. Additionally, the facility failed to document supervision for 2 of 2 residents (Residents 1 & 2) reviewed for accident hazards. Resident 1 experienced harm when they fell from bed and sustained a hip fracture, pain, and hospitalization . This failure placed residents at risk for injury and a diminished quality of life. […]

• Actual harm, isolatedF684Mar 28, 2024

  Based on interview, observation and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when a change of condition was not addressed timely for 1 of 3 residents (Resident 1) and when neurological (neuro) assessments were not consistently performed following unwitnessed falls for 3 of 3 residents (Resident 1, 2, and 3) reviewed for quality of care. Resident 1 experienced harm when they had to be emergently transferred to the hospital when they had a significant change in their baseline cognition and status following an unwitnessed fall. These failures placed residents at risk for medical complications, poor clinical outcomes, unmet care needs, pain, and a diminished quality of life. Findings included . […]

• No harm, potential for more than minimal, widespreadF812Dec 16, 2022

  Based on observation, interview and record review, the facility failed to ensure outdated food products were timely discarded, and to have a system in place that ensured sanitization of cookware, silverware, dishes, and food preparation areas. The facility's failed to timely discard outdated food products, to test the concentration of the sanitizer buckets when replaced, and to act when temperature testing of the facility's high temperature dishwasher (DW) showed it did not meet the minimum temperature required for sanitization. These failures prevented staff from ensuring food was prepared on sanitized surfaces, meals were served on sanitized dishes, residents did not consume outdated food products and placed resident at risk for food-borne illness. […]

• No harm, potential for more than minimal, patternF628Mar 16, 2026

  Based on record review and interview, the facility failed to notify the resident/resident's representative and Ombudsman in writing of the reason for the transfer/discharge to the hospital, convey the required information to the hospital and provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 34, 68, 18 and 66 ) when reviewed for hospitalization. These failures placed the residents at risk for lacking knowledge regarding their transfer, discharge rights and the right to hold their bed while in the hospital and diminished quality of life.Findings included .Resident 34 Review of the electronic health record (EHR) showed Resident 26 admitted to the facility on [DATE] with diagnoses that included left calf ulcer, heart failure and… […]