Tomahawk Health Services

In the surveyor’s words

From the most serious findings on record at Tomahawk Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 1, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent elopement or falls for 2 of 3 residents reviewed (R23, R5).R23 has a history of elopement attempts on and was assessed to be at risk for wandering and elopement. R23 wears a Wanderguard that alerts staff to her attempts to elope. On 02/24/26, R23 exited the facility without staff knowledge and without the Wanderguard alarm sounding. R23 was found by a citizen approximately 0.7 miles from the facility with approximately 1 inch of snow on top of her head. […]

• Actual harm, isolatedF686Nov 3, 2022

  Based on observation, record review, and interview, the facility did not provide preventative care for pressure injuries for 3 of 3 residents (R) reviewed for actual and potential pressure injuries (R196, R17, and R23.) R196 was admitted with pressure injuries. Interventions of the air mattress and wheelchair cushion were not put in place to promote healing and prevent pressure injuries from developing. R196 developed 2 new open areas within 13 days of admission to the facility. The open areas have defined borders and slough that meet the definition of a stage III pressure injury. R17 is at risk for the development of pressure injuries. Surveyor observed R17 up in her wheelchair from 6:30 am until 10:45 am when she was laid down for incontinence care. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2026

  Based on observation and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 48 residents that eat orally. Prepared food placed in the walk-in cooler had been covered but was not labeled or dated, food in dry storage was not covered or dated, and 2 opened containers of milk were in milk cooler without indication of when they were open or when they should be used by resulting in the potential for foodborne illnesses to spread.Findings include:The facility's guidelines titled, Labeling and Dating dated 2017, states in part, All foods should be dated upon receipt before being stored. Food labels must include: the food item name. […]

• No harm, potential for more than minimal, widespreadF880Apr 1, 2026

  Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for all 44 residents in the facility.The facility failed to protect residents from risk of transmission of communicable disease as follows: No airborne precaution signs posted on residents diagnosed with COVID Certified nursing assistant (CNA) staff not using proper N95 masks when entering rooms of positive COVID residents PPE carts stocked with one size N95 masks for all staff to use, despite FIT testing recommendations. […]

• No harm, potential for more than minimal, widespreadF803Jan 15, 2025

  Based on observation, interview and record review, the facility did not follow the menu and did not notify residents of the menu change. This had the potential to affect all 43 residents in the facility. -The facility served a different meal than what was noted on the menu. The facility did notify residents of the menu change. -This resulted in residents complaining of the menu change. -This resulted in one resident (R28) requesting a bowl of cereal for lunch as he did not want what was posted on the menu. R28 was not notified of the menu change and was not given the option to receive the meal that was served. Findings: The facility's policy titled Menus, read in part, Menus will be planned in advance. […]