Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northern Lights Hcc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and chronic respiratory conditions who tested positive for COVID-19 was not consistently monitored or assessed for changes in condition, and the provider was not notified of new or worsening symptoms as required by facility policy and physician orders. Despite multiple documented changes in vital signs and respiratory status, provider notification did not occur until the resident became minimally responsive and hypoxic, resulting in emergency hospital transfer.
The facility failed to report two incidents of possible neglect to the State Agency as required. In one case, a resident with cognitive and physical impairments suffered a fall with fracture that was not reported. In another, a resident with severe cognitive impairment and respiratory issues experienced a decline in condition and a subsequent complaint of neglect, which was also not reported. Leadership interviews revealed confusion about reporting responsibilities and requirements.
The facility did not thoroughly investigate or report two separate incidents involving potential neglect: one involving a resident with severe cognitive impairment who experienced a significant decline in respiratory status without timely provider notification, and another involving a resident with moderate cognitive impairment who suffered an unwitnessed fall resulting in a fracture. In both cases, required investigations and state reporting were not completed, and the facility's own policies were not followed.
Three residents with cognitive and physical impairments experienced multiple falls, including incidents resulting in head laceration and fracture, without thorough root cause investigations, new safety interventions, or consistent care plan updates. Required post-fall assessments, injury monitoring, and IDT reviews were not documented, and interventions were often not adjusted to address the causes of repeated falls.
A resident with Alzheimer's and dementia eloped from a facility through an unalarmed door that was known to not shut properly. The resident's care plan included 15-minute checks, which were not consistently completed, and staff were unaware of the requirement. The door, used frequently by staff, was not repaired despite known issues, and staff were not educated on the door's problems or elopement procedures, leading to a finding of immediate jeopardy.
The facility failed to maintain sanitary conditions in food storage and service, affecting all residents. Expired chocolate milk was found, dishwasher temperature logs were incomplete, and test strips were expired. Staff did not wear hairnets properly, and a cook handled food with contaminated gloves. Maintenance work occurred in the kitchen during meal service without proper hair restraints, and the Nursing Home Administrator did not address the issue.
The facility submitted inaccurate staffing data to CMS, affecting all 39 residents. Due to a payroll system change, data for Quarter 3 2023 was inaccessible, leading to reported failures in 24-hour licensed nursing coverage. Quarter 4 2023 data showed issues like low weekend staffing and no RN hours, but reviews confirmed appropriate scheduling. The inaccuracies were due to incorrect staff coding during data submission.
The facility failed to implement restorative and Functional Maintenance Programs (FMP) for residents, leading to missed opportunities for care. A resident was observed without a required palm protector, and staff were unaware of FMPs due to a lack of formal programs and issues with electronic record transitions. The deficiency affected multiple residents, with care plans missing FMPs until surveyor intervention.
The facility failed to provide adequate staffing, resulting in insufficient care for residents. Staffing levels fell short of the facility's assessment, impacting the implementation of Functional Maintenance Programs, meal assistance, and personal hygiene care. Residents with pressure injuries were not repositioned as required, and staff expressed concerns about chronic understaffing affecting their ability to provide necessary care.
The facility failed to provide required written bed hold notices and reasons for transfer to two residents during hospital transfers, as per their policy. Despite the policy's requirement for such documentation, neither resident received the necessary notices, and the Director of Nursing confirmed this oversight.
A long-term care facility failed to provide adequate assistance with activities of daily living for residents dependent on staff. One resident did not receive proper hygiene care, another was left unsupervised during meals, leading to inappropriate behaviors, and a third was not repositioned or offered toileting assistance for several hours, resulting in incontinence. Staff acknowledged the oversights, and the Director of Nursing confirmed the expectations for care.
A resident with multiple medical conditions, including diabetes and an amputation, was not repositioned regularly, leading to inadequate wound care. The resident was left in a wheelchair for long periods without repositioning or toileting assistance, despite having open sores. Additionally, an LPN failed to follow proper infection control practices during wound care, not changing gloves or sanitizing hands between steps, and incorrectly applying Santyl ointment. Staff interviews confirmed the resident should have been repositioned every two hours, but this was not consistently done.
A resident with multiple pressure injuries did not receive adequate care and prevention measures in a facility. The resident was not repositioned as required, leading to prolonged pressure on existing wounds. The wound nurse inaccurately staged the wounds, and the registered nurse failed to follow proper hand hygiene and wound care procedures. Interviews revealed that the resident was concerned about the lack of repositioning and worsening wounds, while staff confirmed the need for repositioning every two hours.
Two residents were prescribed Trazodone for insomnia without comprehensive sleep assessments or monitoring to evaluate the medication's effectiveness. The facility's policy emphasizes non-pharmacological interventions before medication, but the process of conducting sleep monitoring and assessments was not followed, leading to the deficiency.
CNAs failed to perform hand hygiene as required while providing care to a resident dependent on staff for mobility and hygiene. Despite facility policies mandating handwashing before and after resident contact and between glove changes, CNAs did not adhere to these guidelines during peri-care and other tasks, risking infection spread.
Failure to Notify Provider and Monitor Resident with COVID-19
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including pneumonia, COPD, and chronic respiratory failure, tested positive for COVID-19 and did not receive consistent monitoring and assessment for changes in condition as required by facility policy and physician orders. The resident, who had severe cognitive impairment and was on continuous oxygen therapy, exhibited several changes in symptoms and vital signs over several days, including new onset of wheezing, productive and non-productive cough, elevated temperatures, increased oxygen requirements, and changes in lung sounds. Despite these changes, there was no documentation that the provider was notified in a timely manner, as required by both facility policy and physician orders. The facility's policy required immediate provider notification for acute illness or significant changes in a resident's physical status, including new or worsening symptoms. Physician orders specifically directed staff to monitor for COVID-19 symptoms every shift and to notify the provider immediately if any symptoms were noted. However, documentation showed that after the resident tested positive for COVID-19, there were multiple instances where new or worsening symptoms were observed—such as changes in lung sounds, increased oxygen needs, and elevated temperatures—but the provider was not notified until the resident became minimally responsive and hypoxic several days later. Interviews with nursing staff and the DON confirmed that any new symptoms or changes from baseline, especially in a COVID-19 positive resident, should have prompted immediate provider notification and documentation. The failure to notify the provider and to document these communications was acknowledged by staff and leadership during interviews. The resident was ultimately transferred to the hospital in acute distress with hypoxia and altered mental status, but there was no evidence of provider assessment or intervention between the initial positive COVID-19 test and the emergency transfer.
Failure to Timely Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act and state law. Specifically, the facility did not report two separate incidents involving possible neglect to the State Agency within the required timeframe. In the first case, a resident with moderate cognitive impairment and significant physical limitations experienced an unwitnessed fall resulting in a left humerus fracture. The incident was not reported to the State Agency as possible neglect, and no Misconduct Report was initiated, despite facility policy requiring immediate reporting of such events. In the second case, another resident with severe cognitive impairment and multiple comorbidities, including respiratory failure and emphysema, experienced a decline in respiratory status after testing positive for COVID-19. The resident developed new and worsening symptoms over several days, but the provider was not notified until the resident was found unresponsive and subsequently hospitalized. Following the hospitalization, the resident's POA filed a complaint alleging neglect due to insufficient monitoring and delayed intervention. This allegation was not reported to the State Agency, and no investigation or Misconduct Report was initiated. Interviews with facility leadership revealed confusion and lack of clarity regarding the responsibility and process for reporting such incidents. The Nursing Home Administrator and Director of Nursing provided inconsistent statements about which incidents should be reported and who was responsible for reporting. Both ultimately acknowledged that the incidents should have been reported to the State Agency prior to completing internal investigations, but this did not occur in either case.
Failure to Investigate and Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to thoroughly investigate potential allegations of neglect for two residents. In the first case, a resident with severe cognitive impairment and multiple respiratory diagnoses tested positive for COVID-19 and subsequently developed new and worsening respiratory symptoms over several days. Despite these changes, the provider was not notified until the resident was found unresponsive and required emergency hospitalization. Following this event, the resident's Power of Attorney (POA) filed a complaint alleging neglect, specifically citing concerns that staff did not act on declining oxygen saturation until the resident became unconscious and that the resident was not adequately monitored. The facility did not initiate a thorough investigation into the allegation of neglect, nor did it report the incident to the State agency as required by policy. In the second case, another resident with moderate cognitive impairment, mobility limitations, and a history of falls experienced an unwitnessed fall resulting in a nondisplaced humerus fracture. The incident was discovered by a nurse, and the resident was transferred to the emergency room for evaluation. Although the interdisciplinary team reviewed the fall and implemented new interventions, the root cause of the fall was not clearly identified, and there was no documentation of staff or resident interviews or staff education to prevent future incidents. The incident was not reported to the State agency, and no misconduct report was initiated. In both cases, the facility's actions did not align with its own policy, which requires immediate reporting and thorough investigation of all alleged violations involving neglect. The Director of Nursing acknowledged during interviews that these incidents should have been considered potential neglect and reported accordingly, but this was not done.
Failure to Investigate and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Multiple falls occurred among these residents, some resulting in injuries such as a head laceration and a fracture, yet the facility did not conduct thorough root cause investigations or implement new safety interventions after each incident. In several cases, care plans were not updated following falls, and there was a lack of documentation regarding post-fall assessments, monitoring of injuries, and interdisciplinary team (IDT) reviews as required by facility policy. One resident with severe cognitive impairment and significant physical assistance needs experienced an unwitnessed fall resulting in a head laceration and was transferred to the emergency room. There was no documentation of a root cause investigation, no new interventions were implemented, and the care plan was not updated. Additionally, after returning from the hospital, there was no documentation of monitoring the repaired laceration site for infection or status. This resident had a subsequent fall with similar deficiencies in post-fall investigation and intervention. Another resident with moderate cognitive impairment, hemiplegia, and a history of falls experienced multiple unwitnessed falls, often while attempting to self-transfer. Despite repeated incidents, there was no documentation of root cause investigations, new interventions, or care plan updates. In one instance, the intervention provided was not appropriate given the resident's documented behavior. A third resident with moderate cognitive impairment and a history of falls, including one with a major injury, also experienced multiple falls without consistent root cause analysis, new interventions, or care plan updates. In some cases, interventions implemented were already in place, and there was no documentation of family notification or IDT review.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to adequately supervise a resident at risk for elopement, resulting in the resident leaving the building unsupervised. The resident, diagnosed with Alzheimer's disease and dementia, was assessed as having a severe cognitive impairment and was ambulatory without assistance. Despite being identified as an elopement risk and having a WanderGuard, the resident managed to elope through an unalarmed door, A6, which was known to not shut properly unless pulled tightly. This door was used frequently by staff and was not alarmed, allowing the resident to exit the facility unnoticed. The facility's care plan for the resident included 15-minute checks, which were not consistently documented or completed, particularly on the day of the elopement. The staff responsible for these checks was not aware of the requirement, leading to a lapse in supervision. The resident was found by staff from a nearby assisted living facility and returned by law enforcement, having been outside in freezing temperatures without adequate clothing. The facility's failure to repair the door and ensure staff were informed and compliant with the care plan contributed to the resident's unsupervised exit. Additionally, the facility's maintenance department was aware of the door's issues but had not completed necessary repairs or replacements. Despite receiving parts to fix the door, it remained improperly functioning, and daily checks on the door were not consistently performed. Staff were not formally educated on the door's issues or the procedures to follow in the event of an elopement, further exacerbating the risk to residents. This lack of action and communication led to a finding of immediate jeopardy due to the potential for serious harm to the resident.
Removal Plan
- A6 door alarmed.
- A6 door aligned/adjusted door and hinges.
- Aligned ANSI strike plate on door jam.
- Repaired door closer that was not attached to the door.
- Installed bolts on the screws that were stripped.
- Adjusted the preload on the door closer.
- Close/locked off both back hallway doors.
- Reverse locks so they open with a key.
- Education with SNF staff regarding residents being on 15-minute checks, purpose of 15 minute checks and further direction that need to be completed on the form.
- Direct care staff are to complete the form based on the instructions.
- A6 door audits are checked.
- Maintenance staff has been trained regarding door checks on the A6 door.
Sanitation Deficiencies in Food Storage and Service
Penalty
Summary
The facility failed to ensure food was stored and served under sanitary conditions, which had the potential to affect all 39 residents. During an initial tour of the kitchen, a surveyor observed expired chocolate milk containers in the line cooler, which were five days past their expiration date. The Culinary Director acknowledged the oversight and removed the expired milk, stating it was the responsibility of all dietary staff to dispose of expired items. Additionally, the dishwasher temperature logs were incomplete, with no documented temperatures for a specific period, and the Culinary Director could not explain the lapse. Further observations revealed that the facility's internal dishwasher temperatures were not routinely checked, and the test strips used for high-temperature dish machines were expired. New staff members were unsure of the purpose of these strips. During tray line service, a dietary aide was observed wearing a hairnet improperly, with long hair exposed, and the cook was seen touching ready-to-eat food with contaminated gloved hands. The cook used the same gloves to handle various surfaces and food items without changing them or washing hands, which violated the facility's policy on glove use. The surveyor also noted that during meal service, the Plant Operations Director and a roofer entered the kitchen without hairnets, set up a ladder, and removed a ceiling tile, which was not routine practice. The Nursing Home Administrator witnessed this but did not intervene. The Culinary Director later confirmed that maintenance work should not occur during food service and that all individuals entering the kitchen should wear appropriate hair restraints. These observations highlighted significant lapses in maintaining sanitary conditions in the kitchen, as per the facility's policies.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS was complete, accurate, and auditable, potentially affecting all 39 residents residing in the facility. During the review of the facility's Payroll Based Journal (PBJ) Staffing reports for Quarter 3 2023, Quarter 4 2023, and Quarter 1 2024, it was found that the facility could not provide payroll data for Quarter 3 2023 due to a switch in payroll systems. This resulted in a lack of access to the previous system's data. The PBJ data for Quarter 3 2023 indicated a failure to have licensed nursing coverage 24 hours a day, despite schedules showing that licensed nursing staff were scheduled for all shifts on the infraction dates. For Quarter 4 2023, the PBJ data triggered issues such as excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours a day. However, upon review, RN hours were found to be appropriate, and licensed nursing staff were scheduled for all shifts on the infraction dates. The facility's Director of Nursing confirmed that the inaccurate PBJ data was due to existing staff not being coded correctly when data was submitted. The facility's assessment indicated that licensed nurses were scheduled for 40-48 hours per day, and nurse aides for 96-120 hours per day, which was consistent with the facility's census and assessment.
Failure to Implement Restorative and Functional Maintenance Programs
Penalty
Summary
The facility failed to implement restorative and Functional Maintenance Programs (FMP) to maintain or improve the functional abilities of residents, as observed by surveyors. The deficiency was noted in the care of multiple residents, including one resident who was observed without a palm protector device for her contracted left hand, despite having physician orders and an occupational therapy evaluation recommending its use. The resident's care plan and CNA care card did not address the use of the palm protector or FMP for range of motion (ROM), and there was a lack of data collection showing the completion of the resident's FMPs. The surveyor's investigation revealed that the facility did not have a formal restorative program in place, and there was no quality improvement plan developed to address the concerns related to FMPs not being implemented. The Director of Nursing acknowledged the lack of a formal program and the absence of a performance improvement plan. Additionally, the Assistant Director of Nursing noted that when the facility transitioned to a new electronic medical record system, not all residents' programs were transcribed and transferred, leading to a lack of awareness among staff about the residents' FMPs. The deficiency affected several residents, as their care plans did not include their FMPs until brought to the facility's attention by the surveyor. The lack of implementation of FMPs was a chronic issue, exacerbated by a nursing shortage and the absence of a restorative aide. The surveyor observed that residents were not encouraged or engaged in their restorative programs, and staff were unaware of the residents' FMPs, leading to missed opportunities for care and potential decline in residents' functional abilities.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility's assessment indicated a need for 40-48 hours per day of licensed nurse care and 96-120 hours per day of nurse aide care. However, on certain days, the facility scheduled significantly fewer hours than required, with nurse aide staffing falling short by 29.5 hours on one day and 2 hours on another. This deficiency in staffing levels directly impacted the care provided to residents, as evidenced by the lack of implementation of Functional Maintenance Programs (FMPs) for several residents, including those requiring range of motion exercises and other restorative services. The deficiency in staffing also affected meal assistance and personal hygiene care for residents. One resident, who was dependent on staff for meal assistance, was observed multiple times without adequate supervision or encouragement to eat, leading to potential risks of malnutrition and choking. Additionally, the resident was not repositioned or checked for personal hygiene needs for extended periods, highlighting the facility's inability to meet basic care requirements due to insufficient staffing. This lack of care was further corroborated by staff interviews, where CNAs and LPNs expressed concerns about the chronic understaffing and its impact on their ability to provide necessary care. Furthermore, the facility's failure to reposition residents with pressure injuries or other conditions requiring frequent repositioning was evident. One resident with multiple Stage IV and Stage II pressure injuries was left in the same position for hours without staff intervention, despite the facility's policy of repositioning every two hours. Another resident with a perianal abscess was similarly neglected, with no repositioning or toileting care provided for nearly six hours. These observations underscore the facility's inability to adhere to care plans and protocols due to inadequate staffing, resulting in compromised resident care and well-being.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices and reasons for transfer to residents or their representatives during hospital transfers, as required by their policy. The policy, effective since December 28, 2016, mandates that residents or their representatives receive a written notice regarding bed hold options, including duration, financial obligations, and the readmission process, at the time of or prior to a temporary discharge. However, in the cases of two residents, R19 and R33, the facility did not adhere to this policy. Resident R33, who had previously declined a bed hold upon admission, was transferred to the hospital due to an unresponsive episode, but no written notice of bed hold or reason for transfer was found in their medical record. Similarly, Resident R19 was transferred to the hospital following a change in condition, yet there was no documentation of a bed hold notice or reason for transfer. The Director of Nursing confirmed that the facility did not provide such documentation for these residents, indicating a systemic issue in the facility's adherence to its own bed hold policy.
Failure to Provide Adequate ADL Assistance in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for residents who are dependent on staff, affecting three residents. For one resident, identified as R5, the facility did not ensure proper hygiene care during morning routines. Despite being dependent on staff for hygiene due to impairments, the resident's face and hands were not washed, and a palm guard was not applied as required. The CNA involved acknowledged the oversight, and the Director of Nursing confirmed that washing residents' face and hands is a basic expectation, although not explicitly stated in the facility's policy. Another resident, R29, who has Alzheimer's disease and is always incontinent, was not provided with adequate assistance during meals. The resident was left unsupervised with a meal tray, leading to inappropriate behaviors such as placing non-food items in the mouth. Despite the care plan indicating the need for close supervision and assistance with eating, staff failed to provide consistent support, resulting in the resident not consuming the meal and exhibiting signs of distress. Additionally, the resident was not repositioned or checked for incontinence for extended periods, leading to skin integrity issues. The third resident, R16, who has severe cognitive deficits and is dependent on staff for toileting and transfers, was not repositioned or offered toileting assistance for several hours. Observations revealed that the resident was left in a wheelchair without being checked or changed, resulting in incontinence of both urine and feces. Staff interviews confirmed that the resident should have been repositioned and provided with incontinence care every two hours, but this was not adhered to due to staffing challenges and oversight.
Failure to Reposition and Follow Infection Control Practices
Penalty
Summary
The facility failed to ensure that a resident with wounds received necessary treatment and services to promote healing according to current standards of practice. The resident, who has a history of type 2 diabetes mellitus, heart disease, and an above-knee amputation, was not repositioned regularly, which is crucial for preventing further skin breakdown. Observations revealed that the resident was left in a wheelchair for extended periods without being repositioned or offered toileting assistance, despite having open sores on the buttocks. Additionally, the nursing staff did not adhere to proper infection control practices during wound care. A Licensed Practical Nurse (LPN) was observed not changing gloves or sanitizing hands between steps of the wound dressing process, which is against the facility's protocol and standard infection control practices. The LPN applied Santyl ointment incorrectly on intact skin rather than directly into the wound, which could impede the healing process. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed that the resident should have been repositioned every two hours, but this was not consistently done. The DON and a Registered Nurse (RN) acknowledged the importance of proper hand hygiene and wound care procedures, which were not followed in this case, potentially contributing to the resident's ongoing wound issues.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple pressure injuries. The resident, who has a history of paraplegia, hypertensive heart disease, and other complex medical conditions, was observed not being repositioned or encouraged to offload pressure from the buttocks, which is essential for healing. The resident was found to have three Stage IV and two Stage II pressure injuries, and a new wound developed that was incorrectly documented. The wound nurse inaccurately staged the wounds, and the resident's care plan, which included specific interventions for skin integrity and pressure relief, was not properly followed. During observations, it was noted that the resident was left lying on their back for extended periods without repositioning, contrary to the care plan's directive for repositioning every two hours. The resident's left foot was not properly floated, and the wound nurse failed to identify a wound on the left ankle, which was not documented in the weekly assessments. Additionally, the registered nurse responsible for dressing changes did not practice appropriate hand hygiene, failed to follow the correct wound care procedures, and applied incorrect treatments to the pressure injuries. Interviews with the resident and staff revealed further deficiencies in care. The resident expressed concerns about the lack of repositioning and the worsening of their wounds, while the Director of Nursing confirmed that repositioning should occur every two hours. The wound nurse admitted to incorrectly staging the wounds and acknowledged the risk of worsening pressure injuries due to inadequate repositioning. These observations and interviews highlight significant lapses in the facility's adherence to pressure ulcer care standards, resulting in inadequate treatment and prevention of pressure injuries for the resident.
Inadequate Assessment and Monitoring of Sleep Disturbances
Penalty
Summary
The deficiency involves the inadequate assessment and monitoring of two residents, R11 and R14, for sleep disturbances while using medications to promote sleep. Both residents were prescribed Trazodone for insomnia without comprehensive sleep assessments or monitoring to evaluate the effectiveness of the medication. R11's care plan was developed without a proper assessment of individual needs or monitoring, and there was no sleep assessment or monitoring present in the medical record. Similarly, R14's care plan was created without a comprehensive sleep assessment or monitoring to determine the medication's effectiveness. The facility's policy on psychotropic medication use emphasizes determining the underlying cause of sleep difficulties and utilizing non-pharmacological interventions before resorting to medication. However, the Director of Nursing (DON) acknowledged that the facility's process of conducting a 72-hour sleep monitoring upon admission and completing a sleep assessment for residents with sleep difficulties was not followed for R11 and R14. This oversight led to the development of care plans without proper assessment and monitoring, resulting in the deficiency.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
During a survey, it was observed that Certified Nursing Assistants (CNAs) E and F failed to perform hand hygiene as required while providing morning care to a resident, identified as R5. The facility's policy mandates handwashing before and after resident contact, between glove changes, and after performing any procedure. However, CNA E and F did not adhere to these guidelines. CNA E did not wash hands before donning gloves, after removing gloves, or after performing peri-care. Similarly, CNA F donned gloves without hand hygiene, removed gloves without washing hands, and continued to perform tasks without adhering to hand hygiene protocols. The resident, R5, is dependent on staff for mobility, hygiene, and is incontinent of bowel and bladder, necessitating thorough and consistent hand hygiene to prevent infection. Despite the facility's policies on hand hygiene, both CNAs failed to comply during the care process, including peri-care and transferring the resident using a hoyer lift. The Director of Nursing confirmed the expectation for staff to perform hand hygiene before and after glove use and after peri-care, emphasizing its importance in preventing infection spread.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Court Manor Health Services | 6.6 mi | — | 0 | 0 |
| Ashland Health Services | 7.3 mi | — | 0 | 0 |
| Westgate Nursing & Rehabilitation Community | 36.9 mi | — | 5 | 0 |
| Villa Maria Health And Rehab Ctr | 37 mi | — | 2 | 0 |
| Sky View Nursing Center | 37 mi | — | 0 | 0 |
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