NORTHERN LIGHTS HCC

Nursing Home Inspector

706 BRATLEY DR
WASHBURN, WI 54891
Bayfield County
Phone: 715-373-5621
Provider Number: 525567
Last Inspection: 05/03/2017

About the Nursing Home

Number of Beds: 65
Number of Residents: 59
Beds Available: 6
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

10

Facility
10

County
19

WI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

10

2017
0

2016
43

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/3/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 6/2/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 6/2/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/2/2017
 

4/23/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Widespread : Minimal 5 5/23/2015
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 5/14/2015
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 5/13/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 5/14/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 5/23/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 5/23/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 5/23/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 5/23/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 4/23/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 5/14/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 5/19/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WI State Avg
Number of Residents 59 59.00 64.95
Registered Nurses 1.05 1.05 1.00
Licensed Practical / Vocational Nurses 0.14 0.14 0.56
Certified Nursing Assistants 2.39 2.39 2.54
Total Staff Hours 3.58 3.58 4.11

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% WI State Avg%
of high risk long-stay residents with pressure ulcers 4 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 98
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 97 96
of long-stay residents experiencing one or more falls with major injury 9 9 3
of long-stay residents who have depressive symptoms 6 6 5
of long-stay residents who lose too much weight 9 9 7
of long-stay residents who received an antianxiety or hypnotic medication 11 11 18
of long-stay residents who received an antipsychotic medication 6 6 12
of long-stay residents who self-report moderate to severe pain 2 2 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 22 18
of long-stay residents whose need for help with daily activities has increased 15 15 13
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 4 4 3
of low risk long-stay residents who lose control of their bowels or bladder 37 37 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 93 93 90
of short-stay residents who had an outpatient emergency department visit 10 10 12
of short-stay residents who made improvements in function 88 88 74
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 10 10 18
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 88 86
of short-stay residents who were rehospitalized after a nursing home admission 11 11 18
of short-stay residents who were successfully discharged to the community 63 63 61
of short-stay residents with pressure ulcers that are new or worsened 1 1 0