The Sapphire at Northwoods

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 4, 2026

  Based on interview and record review, the facility failed to implement fall interventions to prevent and/or minimize injury due to falls for 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 6. These failures resulted in R1 sustaining a fall resulting in multiple vertebral fractures which lead to his demise.The findings include:On [DATE] at 3:43 PM, V4, Licensed Practical Nurse (LPN), said R1 was a very high risk for falling. R1 was confused and he would just get up, but he wasn't really able to walk at that time. V4 said R1 just returned during her shift (on [DATE]) from the hospital after falling earlier. V4 said she could hear the thud at the nurse's station, and she automatically knew R1 fell again because he kept falling. […]

• Actual harm, isolatedF684Sep 10, 2025

  Based on interview and record review the facility failed to assess, intervene and implement treatments in a timely manner for a resident (R2) found to have a new injury/bruising to her left shoulder which resulted in a delay in the diagnosis of and treatment of R2's left shoulder dislocation. This failure applies to 1 of 5 residents (R2) reviewed for the necessary care and services in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. […]

• Actual harm, isolatedF689Sep 10, 2025

  Based on observation, interview and record review the facility failed to care for a resident (R2) in a safe manner which resulted in R2 sustaining a left shoulder dislocation. The facility failed to ensure a resident (R2) was safely repositioned in bed, as directed per the resident's care plan. These failures apply to 1 of 5 residents (R2) reviewed for resident safety and supervision in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. […]

• Actual harm, isolatedF689Jul 21, 2025

  Based on interview and record review the facility failed to put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) dated 5/21/25 states, Resident observed laying on the floor next to his bed on his right side. Resident tried to get self up from his bed and slid to the floor. No injuries noted, no pain or discomfort verbalized or demonstrated . Resident transferred back to bed .R1's Care Plan dated 12/17/24 states, Potential for falls, Resident at risk for injury from falls, history of falls. […]

• Actual harm, isolatedF689Jan 2, 2025

  Based on observation, interview, and record review the facility failed ensure safe incontinence care for 1 of 3 residents (R1) reviewed for safety. This failure resulted in R1 rolling off the bed onto the floor and sustaining a cervical fracture, a left clavicle fracture, and laceration to her left eyebrow requiring 3 sutures. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dysphagia, hyperlipidemia, Type 2 Diabetes, spondylosis without myelopathy, generalized anxiety, depression, and arthropathy. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and requires substantial to maximum assist for bed mobility. R1's care plan initiated 6/5/23 showed, . […]