Northern Lights HCC: Fall Safety Failures - WI
The resident, identified in inspection records only as R3, lived at Northern Lights Health Care Center in Washburn, Wisconsin. She had dementia and an unsteady gait. Her own care plan noted that she forgot she could not walk by herself and would attempt to transfer without help. Staff knew this. The record said so, repeatedly, across entries from July through September 2025.
Her first fall came on July 26. She was trying to reach her personal refrigerator and ended up face down on the floor, complaining of pain in her head and right shoulder. Staff assessed her, found no injuries, and notified her provider, the director of nursing, and her family. Five days later, she fell again.
On July 31 at 5:30 PM, a nurse walking past R3's room found her on the floor at the foot of her bed, lying on her left side in a semi-fetal position, her left elbow bent, her palm toward the ceiling. She was yelling that she hurt. She told staff she had been trying to put the footrest down on her recliner, turned around, and fell without her walker. She said she hit her head twice on the floor. She was transferred to the emergency room. The hospital discharged her with a diagnosis of a left nondisplaced humerus fracture, a broken upper arm bone, and instructions to wear a sling and swath continuously.
The facility's interdisciplinary team reviewed both July falls together on August 1 and added new interventions: 15-minute safety checks for 24 hours, lowering the bed at night, and a therapy re-evaluation. Staff discussed her refusal to use her walker with R3 and her power of attorney. The care plan was updated. Inspectors noted, however, that the root cause of the falls had not been clearly identified.
She fell again on September 11, found on the floor between her bed and her wheelchair, saying she had been trying to get into bed. No injuries. New intervention: 15-minute safety checks. The team reviewed the incident the next day and added a plan to have her lie down after supper rather than remain in her wheelchair in the room, where she might try to transfer herself.
On September 28, a nurse walking by noticed R3 was no longer in her wheelchair where she had last been seen. She was found on the floor on her left side, her head near the end of the bed, unable to say what had happened. She complained of pain in her left knee. Because of the fracture two months earlier, staff transferred her to the emergency room. Her power of attorney declined radiological imaging, and she returned to the facility without documented injuries.
What did not happen after that fall is what inspectors flagged. No root cause investigation was documented. No new interventions were put in place. The care plan was not updated. The interdisciplinary team did not conduct or document a review of the incident.
Then came October 25, at 11:35 PM. R3 was found lying on the floor next to her dresser, pants around one ankle. Nursing notes described what appeared to have happened: she had walked to her dresser and tried to put on a pair of pants. She had a small skin tear on her left elbow. Staff cleaned the wound and applied a dressing. Her provider was notified by a note left in a rounding book.
Again, no root cause investigation. No new interventions. No care plan update. The one intervention staff did document, placing the bed in a low position, was already listed on the existing care plan. The interdisciplinary team did not review the fall. And there was no documentation that anyone notified her family.
Inspectors cited the facility under the federal tag governing accident prevention, F0689, and rated the violation as causing minimal harm or potential for actual harm.
The broken arm from July was real. The skin tear from October was real. Between them, two falls passed through a facility that had her history, her diagnosis, and her pattern, and produced no documented effort to understand why she kept ending up on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Lights Hcc from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
NORTHERN LIGHTS HCC in WASHBURN, WI was cited for violations during a health inspection on November 12, 2025.
The resident, identified in inspection records only as R3, lived at Northern Lights Health Care Center in Washburn, Wisconsin.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.