Northern Lights Hcc

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

spoke with Resident R1's family about their concerns. At this time, DON B provided Surveyor with a copy of the email DON B sent to the provider and NHA regarding Resident R1's POA concerns and what the ER provider stated to Resident R1's POA on 10/06/25. DON B stated that Resident R1's POA was told by the ER provider that there was no way Resident R1's respiratory condition declined that fast and that the facility should have intervened earlier to prevent

this worsening. Surveyor asked DON B if this concern could be considered neglect. DON B stated yes.

Surveyor asked DON B if this concern could be neglect, should it have been reported to the State agency and investigated to determine if neglect had occurred. DON B stated yes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Lights Hcc

706 Bratley Dr Washburn, WI 54891

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm

DON B regarding this incident. DON B stated being unclear as to when falls with injuries had to be reported. DON B stated recognition in hindsight that this could have been potential neglect, and it should have been investigated further.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Lights Hcc

706 Bratley Dr Washburn, WI 54891

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

regarding assessments and notifying provider with changes of condition. Surveyor asked DON B if an assessment noted a change in lung sounds in a resident known COVID-19 positive should be reported to

the provider. DON B stated absolutely, and that the communication should be documented in the resident's chart. Surveyor reviewed the timeline documented in Resident R1's medical chart noting that when changes were noted, the provider was not notified. DON B stated that when the nurse noticed a new cough, changes in lungs sounds, and the elevated temperature from baseline should have been communicated to the provider immediately.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Lights Hcc

706 Bratley Dr Washburn, WI 54891

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unsteady gait and dx of dementia. Resident forgets that she cannot walk by herself and self-transfers at times.9/14/25 At risk: Resident is at risk for falls due to unsteady gait and dx of dementia. Resident forgets that she cannot walk by herself and self-transfers at times.9/28/25 At risk: Resident is at risk for falls due to recent previous falls, unsteady gait, and safety/memory/judgement/cognition problems.Resident R3's Falls:On 07/26/25 at 1:00 PM, Resident R3 had unwitnessed fall in room. Resident R3 was found on floor, face down in front of recliner. Resident R3 stated knee was bad and trying to get into personal refrigerator. Resident R3 complained of pain to head and right shoulder. Resident R3 assessed and noted no injuries. Provider, DON, and family notified. IDT reviewed and investigation completed.On 07/31/25 at 5:30 PM, Resident R3 had unwitnessed fall in room. Nurse found Resident R3 on floor while walking by Resident R3's room. Nurse observed Resident R3 on floor at foot of bed, lying on left side in a semi-fetal position. Resident R3's head was toward doorway and feet toward windows. Resident R3's left elbow bent with palm towards ceiling and up off floor about 30 degrees. Resident R3 was yelling she hurts. Resident R3 assessed and complained of pain in left shoulder, left hip, and all over. Resident R3 stated trying to put footrest down on the recliner chair, turned around and fell. Resident R3 stated she was not using her walker and hit her head twice on the floor. Provider, DON, and family notified. Resident R3 was transferred to ER. IDT reviewed and investigation completed.-Hospital notes: 07/31/25: Chief complaint: left arm/shoulder pain related to fall. Discharge diagnosis: left nondisplaced humerus fracture. Discharge instructions: continuous use of left arm sling and swath; follow-up with primary provider.On 08/01/25: IDT Reviewed falls from 07/26/25 and 07/31/25 simultaneously. New interventions implemented: 15-minute safety checks completed for 24 hours, bed at low height at HS, and therapy to re-evaluate. Resident R3's noncompliance with using walker during ambulation was assessed and discussed with Resident R3 and Resident R3's POA. Care plan updated.-Of note: Root cause was not clearly identified.On 09/11/25 at 7:30 PM, Resident R3 had unwitnessed fall in room. Resident R3 was found on floor between bed and wheelchair. Resident R3 stated falling while trying to get into bed. Resident R3 was assessed and no injuries noted. New intervention: 15-minute safety checks. Provider, DON, NHA, and family notified.On 09/12/25: IDT reviewed fall. Medications and chart reviewed. Cause determined to be self-transferring. New interventions: 15-minute safety checks (completed for 24 hours) and to lay down after supper and not to be left in wheelchair in room after supper to prevent self-transfer. Care plan updated.On 09/28/25 at 4:00 PM, Resident R3 had unwitnessed fall in room. Nurse walking by Resident R3's room observed Resident R3 was not in wheelchair where last observed. Resident R3 was found lying on floor on left side with head by end of bed. Resident R3 then called for assistance. Resident R3 was unable to state what happened. Resident R3 complained of pain in left knee. Resident R3 was assessed and no injuries noted. Provider and family notified. Due to prior fracture related to fall, Resident R3 was transferred to ER for evaluation.-Of note: Resident R3's POA declined to have any radiological imaging completed in ER and Resident R3 returned to facility without any noted injuries. No documentation of root cause investigation, no new interventions implemented, and care plan not updated.

No IDT review of incident documented.On 10/25/25 at 11:35 PM, Resident R3 had unwitnessed fall in room. Resident R3 was found lying on floor next to dresser with pants around one ankle. Nursing description: Resident R3 appears to have walked to her dresser and tried to put on a pair of pants. No documentation of Resident R3 stating what happened. Resident R3 was assessed and noted to have a small skin tear on left elbow. Wound was cleansed and dressing placed. Provider notified via note in rounding book. Intervention: bed placed in low position.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated.

Intervention implemented was already noted on care plan in place. No IDT review of incident documented.

No documentation of family notification noted.

Event ID:

Facility ID:

If continuation sheet