Northern Lights Hcc
NORTHERN LIGHTS HCC in WASHBURN, WI — inspection on November 12, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
spoke with 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 R1's POA concerns and what the ER provider stated to R1's POA on 10/06/25. DON B stated that R1's POA was told by the ER provider that there was no way 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northern Lights Hcc
706 Bratley Dr Washburn, WI 54891
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northern Lights Hcc
706 Bratley Dr Washburn, WI 54891
SUMMARY STATEMENT OF DEFICIENCIES
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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northern Lights Hcc
706 Bratley Dr Washburn, WI 54891
SUMMARY STATEMENT OF DEFICIENCIES
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.R3's Falls:On 07/26/25 at 1:00 PM, R3 had unwitnessed fall in room. R3 was found on floor, face down in front of recliner.
R3 stated knee was bad and trying to get into personal refrigerator. R3 complained of pain to head and right shoulder. R3 assessed and noted no injuries.
Provider, DON, and family notified. IDT reviewed and investigation completed.On 07/31/25 at 5:30 PM, R3 had unwitnessed fall in room.
Nurse found R3 on floor while walking by R3's room.
Nurse observed R3 on floor at foot of bed, lying on left side in a semi-fetal position. R3's head was toward doorway and feet toward windows. R3's left elbow bent with palm towards ceiling and up off floor about 30 degrees. R3 was yelling she hurts. R3 assessed and complained of pain in left shoulder, left hip, and all over. R3 stated trying to put footrest down on the recliner chair, turned around and fell. R3 stated she was not using her walker and hit her head twice on the floor.
Provider, DON, and family notified. 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. R3's noncompliance with using walker during ambulation was assessed and discussed with R3 and R3's POA.
Care plan updated.-Of note: Root cause was not clearly identified.On 09/11/25 at 7:30 PM, R3 had unwitnessed fall in room. R3 was found on floor between bed and wheelchair. R3 stated falling while trying to get into bed. 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, R3 had unwitnessed fall in room.
Nurse walking by R3's room observed R3 was not in wheelchair where last observed. R3 was found lying on floor on left side with head by end of bed. R3 then called for assistance. R3 was unable to state what happened. R3 complained of pain in left knee. R3 was assessed and no injuries noted.
Provider and family notified.
Due to prior fracture related to fall, R3 was transferred to ER for evaluation.-Of note: R3's POA declined to have any radiological imaging completed in ER and 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, R3 had unwitnessed fall in room. R3 was found lying on floor next to dresser with pants around one ankle.
Nursing description: R3 appears to have walked to her dresser and tried to put on a pair of pants. No documentation of R3 stating what happened.
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.
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