North Woods Home Nursing

The agency failed to ensure that Skilled Nursing (SN) assumed responsibility for the appropriate management of acute congestive heart failure in 1 (P-13) 3 records reviewed with congestive heart failure (See G 704); failed to ensure services were provided as ordered in the plan of care for 4 (P-5…

The agency failed to ensure 2 (2025 and 2026) of 2 Emergency Preparedness (EP) drills included all required documentation, resulting in the potential for an unprepared staff response in the event of an emergency.

The agency failed to ensure the ordered skilled nurse visit frequency was honored for 1 (P-6) of 1 patient, resulting in the potential for unidentified health concerns and unmet care needs.

The agency failed to ensure that Skilled Nursing (SN) assumed responsibility for the appropriate management of acute CHF (congestive heart failure) in 1 (P-13) 3 records reviewed with CHF, resulting in unmonitored exacerbation of CHF symptoms, hospitalization and poor clinical outcomes.

The agency failed to ensure the aide care plan included patient specific care instructions for 1 (P-7) of 3 records reviewed of patients who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure that 2 (P-4 and P-5) of 2 patients were included in the overall planning of care; and failed to ensure patients consented to services provided in 1 (P-9) of 1 record, resulting in the lack of inclusion in planning, the potential for missed visits, and unmet care needs.

The agency failed to ensure the patient received written Notice of Medicare Non-Coverage (NOMNC) in advance of terminating ongoing home care services for 2 (P-6, P-13) of 4 discharged patients, resulting in patients not having the right or opportunity to dispute the termination of Medicare covered…

The agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral for 2 (P-4 and P-9) of 2 patients, resulting in the delay of needed services and the potential for decline in health status.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history in 5 (P-2, P-3, P-7, P-8, and P-9) of 13 records reviewed, resulting in incomplete clinical information to assist in determining the…

The agency failed to ensure skilled nursing performed an updated medication reconciliation following an in-patient hospital discharge in 1 (P-13) of 1 record; and failed to ensure the patient's clinical record documented all medications and documented evidence that the physician was notified of…

The agency failed to update the comprehensive assessment after a significant change in condition for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the Plan of Care (POC) was complete and included safety parameters to protect against injury/harm in all 13 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-12, P-13) of 13 records reviewed, resulting in the potential for unreported clinical results and poor…

The agency failed to ensure its disciplines promptly reported changes in patient's conditions for 3 (P-2, P-4, P-5) of 3 patients with vital signs outside of the reportable parameters, resulting in the potential for unidentified, untreated health concerns.

The agency failed to ensure skilled professionals provided ongoing assessments to meet the needs of the patient for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure services were provided as ordered in the plan of care for 3 (P-5, P-6, and P-8) of 3 patients, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure skilled professionals prepared clinical notes per agency expectation for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure Skilled Nursing (SN) notified the physician of significant weight gain in 1 (P-13) of 1 record reviewed with a resumption of care after hospitalization.

The agency failed to ensure home health aides provided services as ordered in the plan of care for 1 (P-9) of 3 records reviewed of patients who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the clinical record was complete and contained accurate documentation for 3 (P-2, P-4, P-13) of 3 patients, resulting in the potential for unidentified, untreated health concerns, lack of continuity of care and unmet patient care needs.

The agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 4 (P-3, P-6, P-8, and P-13) of 4 records in which the…

The agency failed to ensure the initial comprehensive assessment was completed no later than 5 calendar days after the start of care in 1 (Patient #16) of 17 records reviewed, resulting in the potential for unidentified patient needs.

The agency failed to ensure coordination of care occurred to ensure patient needs were identified and communicated to the appropriate professional in 1 (Patient #17) of 17 records reviewed, resulting in the potential for unmet care needs and negative outcomes.

The agency failed to ensure a written visit schedule including frequency of visits for each discipline was provided to the patient in 3 (Patient #15, 16, 17) of 7 records with home visits, resulting in the potential for the patient to not be informed of the plan of care or the expected staff visits.

The agency failed to ensure written medication instructions including the medication names; dosages; and frequencies, were provided to the patient and caregiver for 1 of 7 (P-4) patients for which a home visit was conducted resulting in the potential for medication errors with poor patient outcomes.

The agency failed to ensure patient goals were specific and measurable in the patient's plan of care due to lack of baseline information in the evaluation in 1 (Patient #17) of 17 records reviewed, resulting in an inability to accurately assess patient status and need for continuing care.

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner within 5 days after discharge in 1 of 5 (P-5) sample discharge records reviewed potentially resulting in unmet patient care needs due to a lack of coordination of patient care.