Inspection Reports for North Ridge Health and Rehabilitation Center
1445 North 7th Street, Manitowoc, WI 54220, Manitowoc, WI, 54220
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 10, 2025
Visit Reason
The inspection was conducted based on a complaint regarding the use of physical restraints on a resident (R49) without proper medical justification, order, or care plan documentation.
Complaint Details
The complaint investigation found that the restraint mitt was used for discipline or convenience rather than medical necessity. The restraint was not ordered by a practitioner, and no assessments or care plan updates were documented. The Director of Nursing and Nurse Practitioner confirmed the restraint was inappropriate and removed it.
Findings
The facility failed to ensure freedom from physical restraints for resident R49, who was found wearing a restraint mitt without an order, assessment, or care plan. Staff interviews and record reviews confirmed the restraint was used to prevent the resident from pulling on a feeding tube, but the restraint was not medically justified or properly documented.
Deficiencies (1)
Use of physical restraints on resident R49 without medical order, assessment, or care plan documentation.
Report Facts
Dates of observation: Restraint mitt observed on 12/8/25 and 12/9/25
MDS assessment date: Most recent MDS assessment dated 9/4/25
BIMS score: 0
Hospitalization date: Resident hospitalized on 11/12/25
Nurse Practitioner visit notes dates: Visits on 11/24/25 and 11/26/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing -B | Director of Nursing | Verified restraint mitt use without order or care plan and removed mitt after interview |
| Nurse Practitioner -C | Nurse Practitioner | Observed restraint mitt on resident during visits and confirmed no order for restraint mitt |
| Registered Nurse -D | Registered Nurse | Verified resident was wearing restraint mitt but was unsure why |
| Registered Nurse -E | Registered Nurse | Indicated restraint mitt was used to prevent resident from pulling feeding tube |
| Certified Nursing Assistant -F | Certified Nursing Assistant | Verified restraint mitt use to prevent pulling feeding tube and trach, unsure who applied mitt |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 10, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including protective placement, PASRR screening, accident prevention, dialysis care, pharmaceutical services, and food safety at North Ridge Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure protective placement for a resident with a legal guardian, incomplete PASRR Level II screening for a resident with a new mental illness diagnosis, inconsistent monitoring of a WanderGuard device, incomplete dialysis assessments and documentation, lack of proper medication self-administration assessments, and unsafe food storage and preparation practices.
Deficiencies (6)
Failure to ensure protective placement for a resident with a legal guardian as required by state statute.
Failure to complete PASRR Level II screening for a resident with a qualifying diagnosis and prescribed medication.
Inconsistent checking and documentation of WanderGuard placement, function, and skin integrity for a resident at risk of elopement.
Failure to consistently complete pre- and post-dialysis assessments, vital signs, weights, and communication documentation for a resident receiving dialysis.
Medications left at resident bedside for self-administration without a self-administration assessment, physician order, or care plan.
Food safety violations including failure to monitor dishwasher wash and rinse temperatures, uncovered mixer bowl, and staff not consistently covering facial hair.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding protective placement and PASRR screening |
| Social Worker H | Social Worker | Interviewed regarding protective placement and PASRR screening |
| Director of Nursing B | Director of Nursing | Interviewed regarding WanderGuard monitoring, dialysis care, and medication self-administration |
| Licensed Practical Nurse K | Licensed Practical Nurse | Interviewed regarding WanderGuard monitoring and observed leaving medications at bedside |
| Registered Nurse G | Registered Nurse | Interviewed regarding dialysis care and documentation |
| Dietary Manager I | Dietary Manager | Interviewed regarding food safety and dishwasher temperature monitoring |
| Dietary Aide J | Dietary Aide | Observed not wearing beard net during food preparation |
| Certified Kitchen Worker L | Certified Kitchen Worker | Observed operating dishwasher with improper temperatures |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and medication administration policies at North Ridge Health and Rehabilitation Center.
Findings
The facility failed to ensure accurate medication administration for 4 of 9 sampled residents and did not consistently reconcile narcotic medications, resulting in missing controlled substance count signatures across multiple shifts.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Report Facts
Residents sampled: 9
Residents affected: 4
Total residents in facility: 57
Missing signatures: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-D | Registered Nurse | Administered medications to residents R3, R4, and R5; interviewed regarding medication administration times |
| DON-B | Director of Nursing | Interviewed regarding medication administration policies and controlled substance record education |
| RN-E | Registered Nurse | Interviewed regarding responsibilities for controlled substance counts and signatures |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care and prevention at North Ridge Health and Rehabilitation Center.
Findings
The facility failed to ensure that one resident with a stage 3 pressure injury received appropriate wound care according to physician orders, resulting in wound infection requiring intravenous antibiotics and surgical debridement. The wound care management was inconsistent, including use of incorrect dressings and failure to properly cleanse wounds, contributing to worsening of the wound condition.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Wound measurements: 8
Wound measurements: 3
Wound measurements: 0.1
Wound measurements: 11
Wound measurements: 9
Temperature: 102
Antibiotic treatment duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APNP-E | Advanced Practice Nurse Prescriber | Documented wound measurements and treatment orders; interviewed by surveyor regarding wound care |
| WRN-G | Wound Registered Nurse | Informed family member about wound worsening and incorrect dressing; interviewed by surveyor |
| LPN-D | Licensed Practical Nurse | Applied dressing to resident's wound; interviewed by surveyor |
| DON-B | Director of Nursing | Interviewed by surveyor regarding wound care policies and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 25, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to notify a resident's representative of a change in condition, inadequate supervision leading to elopement, unsafe food handling practices, and infection prevention and control deficiencies.
Complaint Details
The complaint investigation included failure to notify a resident's representative of a change in condition, inadequate supervision leading to elopement, unsafe food handling practices, and infection prevention and control deficiencies. Immediate jeopardy was identified related to the elopement incident but was removed after corrective actions were implemented.
Findings
The facility failed to notify a resident's representative of a significant change in condition, failed to provide adequate supervision to prevent elopement resulting in immediate jeopardy, did not ensure safe and sanitary food handling practices including proper hair restraints, hand hygiene, and food temperature control, and failed to maintain an effective infection prevention and control program including proper use of PPE and hand hygiene during resident care.
Deficiencies (4)
Failure to notify resident representative of change in condition and treatment for 1 resident.
Failure to provide adequate supervision to prevent elopement for 1 resident, resulting in immediate jeopardy.
Food was not stored, prepared, or served in a safe and sanitary manner; staff did not consistently wear hair restraints; kitchen cleanliness was inadequate; hand hygiene was not followed; and food/beverages were served at inappropriate temperatures.
Failure to implement infection prevention and control program including improper PPE use and inadequate perineal care for 2 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 39
Residents affected: 2
Temperature readings: 110.1
Temperature readings: 129.5
Temperature readings: 55.7
Temperature readings: 60.2
Temperature readings: 61.7
Temperature readings: 139.5
Temperature readings: 110.6
Temperature readings: 139.2
Temperature readings: 120.7
Temperature readings: 117.4
Temperature readings: 60
Temperature readings: 58.4
Temperature readings: 58.8
Temperature readings: 60.8
Temperature readings: 146.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| POAHC-H | Power of Attorney for Healthcare | Named in failure to notify resident representative deficiency |
| DON-B | Director of Nursing | Interviewed regarding notification and supervision deficiencies |
| NHA-A | Nursing Home Administrator | Interviewed regarding elopement immediate jeopardy and food service issues |
| RN-M | Registered Nurse | Found eloped resident and described alarm response |
| CNA-L | Certified Nursing Assistant | Reported door alarm and described inability to hear alarm |
| CK-F | Cook | Observed with improper hair and beard restraints and improper hand hygiene |
| DD-E | Director of Dining | Interviewed regarding food safety, hair restraints, hand hygiene, and temperature control |
| CNA-C | Certified Nursing Assistant | Observed not completing hand hygiene and improper perineal care |
| RN-M | Registered Nurse | Entered resident room without PPE on contact precautions |
Inspection Report
Routine
Deficiencies: 14
Date: Aug 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, medication administration, infection control, pressure ulcer care, dialysis care, staffing data submission, and food safety.
Findings
The facility was found deficient in multiple areas including failure to follow advance directive wishes and guardianship orders, incomplete medication self-administration assessments, inadequate call light accessibility, lack of advance directives documentation, failure to provide proper transfer and bed hold notices, inadequate pressure ulcer care, unsafe smoking assessments, incomplete dialysis vital signs and weight documentation, expired medications and unlocked medication carts, poor infection control practices, and inaccurate staffing data submission to CMS.
Deficiencies (14)
Failure to ensure guardianship and protective placement orders were obtained and advance directive wishes were followed for 4 residents.
Failure to assess 3 residents as able to safely and accurately self-administer medication.
Failure to ensure 1 resident had a call light within reach as per care plan.
Failure to ensure medical record contained advance directives for 1 resident.
Failure to provide timely notification of transfer, reason, location, appeal rights, and ombudsman contact to 3 residents or their representatives.
Failure to notify 3 residents or their representatives in writing of the bed hold policy duration and right to return.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for 1 resident; wound care orders and care plan interventions were not implemented as ordered.
Failure to ensure the resident environment was free from accident hazards and provide adequate supervision for 1 resident who smoked; quarterly smoking assessments were not completed timely.
Failure to ensure vital signs and weights were consistently completed pre- and post-dialysis and communicated to the dialysis facility for 1 resident.
Failure to ensure monthly medication reviews were completed or followed-up on for 2 residents; pharmacist recommendations were not addressed timely or at all.
Failure to ensure all drugs and biologicals were stored properly; medication carts were unlocked and unattended, and expired medications and supplies were found in medication carts and storage rooms.
Failure to ensure food was stored and prepared in a sanitary manner; kitchen equipment and food service areas were not clean, staff did not perform appropriate hand hygiene or safe food handling, and food holding temperatures were not documented.
Failure to maintain an infection prevention and control program; staff did not perform appropriate hand hygiene, wear masks or PPE as required during care of residents on precautions, and did not follow infection control policies.
Failure to ensure accurate submission of mandatory staffing information based on payroll data to CMS; data for two fiscal quarters were inaccurately submitted.
Report Facts
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication carts unlocked: 3
Medication carts with expired meds: 2
Medication storage rooms with expired meds: 1
Residents affected: 7
Fiscal quarters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW-D | Social Worker | Interviewed regarding guardianship paperwork and transfer/bed hold notices |
| NHA-A | Nursing Home Administrator | Interviewed regarding admission, transfer notices, staffing data submission |
| DON-B | Director of Nursing | Interviewed regarding medication self-administration, wound care, infection control, expired meds |
| LPN-U | Licensed Practical Nurse | Observed and interviewed regarding medication self-administration and hand hygiene |
| RN-K | Registered Nurse | Observed and interviewed regarding medication administration and infection control |
| RN-N | Registered Nurse | Interviewed regarding dialysis care and infection control |
| APNP-G | Advance Practice Nurse Practitioner | Observed and interviewed regarding wound care and infection control |
| RN-F | Registered Nurse | Observed and interviewed regarding wound care |
| RN-H | Registered Nurse | Interviewed regarding wound care documentation |
| CNA-M | Certified Nursing Assistant | Observed and interviewed regarding mask use and infection control |
| PT-T | Physical Therapist | Observed and interviewed regarding PPE use during therapy |
| CK-P | Cook/Kitchen Staff | Observed and interviewed regarding hand hygiene during food service |
| DM-E | Dietary Manager | Interviewed regarding kitchen cleanliness and food safety |
| CBOM-I | Corporate Business Office Manager | Responsible for staffing data submission, did not respond to Surveyor |
| AIT-C | Administrator In Training | Interviewed regarding staffing data submission |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 9, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate care and treatment for residents, including failure to document and notify physicians timely about changes in residents' conditions, failure to obtain ordered weights for residents with feeding tubes, improper food preparation and serving practices, and unsanitary food handling.
Complaint Details
The complaint investigation focused on concerns about delayed care and notification for a resident with a change of condition, missing weights for residents with feeding tubes, improper food preparation and serving, unsafe food temperatures, and poor hand hygiene and food handling practices.
Findings
The facility failed to provide appropriate care and timely notification for a resident with a change of condition, did not obtain ordered weights for residents with feeding tubes, did not follow pureed food recipes or serving sizes, served pasta salad at unsafe temperatures, and did not ensure proper hand hygiene and sanitary food handling practices in the kitchen.
Deficiencies (5)
Failure to provide appropriate care and timely notification for a resident experiencing a change of condition.
Failure to obtain ordered weights for residents with feeding tubes as per physicians' orders.
Failure to prepare pureed food according to recipe and serve appropriate portion sizes.
Serving pasta salad at unsafe and unappetizing temperatures above 41 degrees Fahrenheit.
Failure to perform proper hand hygiene and unsanitary food handling practices including touching ready-to-eat food and garbage can lids without hand hygiene or gloves.
Report Facts
Missing daily weights: 48
Missing weekly weights: 6
Temperature of pasta salad: 61.7
Temperature of pasta salad: 60
Temperature of pasta salad servings: 56.1
Temperature of pasta salad servings: 53.8
Temperature of pasta salad servings: 54.1
Temperature of pasta salad servings: 52.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-C | Registered Nurse | Assigned nurse who failed to document assessments and timely notify physician for resident R1's change of condition. |
| DON-B | Director of Nursing | Interviewed regarding expectations for notification and documentation related to resident R1 and verification of missing weights for residents R10 and R11. |
| DM-F | Dietary Manager | Interviewed regarding food preparation, serving sizes, food temperature policies, and hand hygiene training. |
| CK-G | Cook | Observed not following pureed food recipe, improper measuring, and serving pasta salad at unsafe temperatures. |
| NHA-A | Nursing Home Administrator | Interviewed regarding expectations for care, food preparation, and hand hygiene compliance. |
Inspection Report
Routine
Census: 52
Deficiencies: 2
Date: May 20, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and infection prevention standards during routine operations at the nursing home.
Findings
The facility failed to serve milk at a safe and appetizing temperature, with milk measured at 53.6 degrees Fahrenheit, exceeding the recommended 32-40 degrees. Additionally, staff did not consistently perform appropriate hand hygiene during food preparation, increasing the risk of foodborne illness.
Deficiencies (2)
Did not ensure milk was served at a safe and appetizing temperature.
Did not ensure staff performed appropriate hand hygiene during food preparation.
Report Facts
Residents present during inspection: 52
Milk temperature: 53.6
Milk temperature: 42.8
Recommended milk temperature range: 32
Recommended milk temperature range: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CK-C | Kitchen staff observed preparing food and serving milk; did not perform proper hand hygiene | |
| Dietary Manager (DM)-D | Interviewed and verified milk temperature was too warm and hand hygiene lapses |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care according to professional standards for one resident who experienced a change in condition leading to hospitalization for septic shock.
Complaint Details
The complaint investigation found that the facility did not substantiate proper monitoring and documentation for Resident 2 after a change in condition, leading to hospitalization for septic shock. The resident was not assessed by nursing staff from 10/11/23 through 10/15/23 or on 10/17/23, and was not included in the facility's 24-hour monitoring reports during this period.
Findings
The facility did not ensure proper monitoring and documentation of a resident's edema and weight after a physician's orders, resulting in missed assessments and failure to obtain a urinalysis. The resident was hospitalized with septic shock related to a urinary tract infection and pneumonia. Nursing staff failed to include the resident in 24-hour monitoring reports and did not assess the resident during critical days of condition changes.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in inadequate monitoring and documentation of a resident's condition.
Report Facts
Dates missing from 24 hour reports: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-C | Registered Nurse | Interviewed regarding importance of entering physician orders for weight and edema monitoring and documentation. |
| DON-B | Director of Nursing | Interviewed regarding staff expectations for monitoring and documentation of resident condition and verification of incomplete 24 hour report sheets. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint filed by Resident 4 (R4) regarding inadequate grievance handling and disrespectful care by a Certified Nursing Assistant (CNA-C).
Complaint Details
The complaint was substantiated for Resident 4 (R4). R4 reported that CNA-C did not treat residents respectfully and failed to change a Chux Pad properly. R4 filed a grievance with the Director of Nursing (DON-B), who assured R4 that CNA-C would not provide care. However, CNA-C continued to care for R4 with the same attitude. DON-B did not follow up adequately, and documentation was lacking.
Findings
The facility failed to ensure that a grievance filed by R4 was properly documented, investigated, and resolved. Despite assurances that CNA-C would not care for R4, CNA-C continued to provide care with the same negative attitude. The facility's grievance policy was not fully followed, and documentation and follow-up were insufficient.
Deficiencies (1)
Failure to file, investigate, and resolve a grievance for 1 resident regarding disrespectful care and inadequate follow-up.
Report Facts
Residents reviewed: 7
BIMS score: 15
Date of grievance incident: Aug 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Named in grievance handling and investigation related to Resident 4 |
| NHA-A | Nursing Home Administrator | Interviewed regarding grievance and facility expectations for follow-up |
| CNA-C | Certified Nursing Assistant | Named in grievance for disrespectful care and failure to change Chux Pad properly |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 14, 2023
Visit Reason
The inspection was a routine survey of North Ridge Health and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, nutrition, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required PASRR screenings for residents with mental disorders, incomplete baseline care plans for new admissions, inadequate assistance with activities of daily living such as weekly showers, inconsistent nutritional monitoring including weight checks and feeding tube rates, lack of monitoring for side effects of high-risk medications, insufficient food service management qualifications, improper food portioning and preparation, unsanitary food storage and preparation practices, failure to maintain proper food temperatures, and inadequate infection prevention and control practices including improper glove use and hand hygiene.
Deficiencies (10)
Failure to provide Pre-admission Screening and Resident Review (PASRR) services for 4 of 5 sampled residents and incomplete PASRR Level II screenings.
Baseline care plan was not developed within 48 hours of admission for 1 resident with complex medical needs including tracheostomy, gastrostomy, and ventilator dependence.
Two residents did not receive weekly showers as required.
Weights were not consistently obtained weekly for 2 residents, and tube feeding rates were not followed as ordered.
High-risk medications such as diuretics and psychotropic drugs were not monitored for potential side effects in 2 residents.
Facility did not employ a qualified dietary manager with appropriate certification or degree.
Menu serving sizes for pureed and mechanically altered diets were not followed, resulting in smaller portions than indicated.
Pureed foods were prepared using water which did not conserve nutritive value or palatability.
Food was not stored and prepared in a sanitary manner; sanitizing solutions were not tested per manufacturer instructions; microwave reheated food was not stirred or allowed to stand; food-contact equipment was dirty; hot holding temperatures were not monitored or documented; and foods were cooled improperly.
Infection prevention and control program deficiencies included improper glove use and hand hygiene by staff during resident care, and lack of a staff infection line list to monitor illness.
Report Facts
Residents affected by PASRR deficiency: 4
Residents affected by baseline care plan deficiency: 1
Residents affected by missed showers: 2
Residents affected by weight monitoring deficiency: 2
Residents affected by medication monitoring deficiency: 2
Residents affected by food portion deficiency: 8
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator (AC)-I | Admissions Coordinator | Verified PASRR screening deficiencies for residents R30, R53, R44, and R50. |
| Director of Nursing (DON)-B | Director of Nursing | Verified deficiencies related to baseline care plans, medication monitoring, weight monitoring, and infection control. |
| Certified Nursing Assistant (CNA)-F | Certified Nursing Assistant | Interviewed about missed resident cares including showers. |
| Certified Nursing Assistant (CNA)-G | Certified Nursing Assistant | Interviewed about missed resident cares including showers. |
| Unit Manager (UM)-D | Unit Manager | Verified expectations for weekly showers and weight monitoring. |
| Registered Dietitian (RD)-H | Registered Dietitian | Provided nutritional evaluations and confirmed food safety and preparation deficiencies. |
| Dietary Manager (DM)-L | Dietary Manager | Confirmed lack of certification and knowledge of food safety standards. |
| Cook (CK)-N | Cook | Observed preparing and serving food improperly including portioning and reheating. |
| Certified Nursing Assistant (CNA)-K | Certified Nursing Assistant | Observed providing perineal care with improper glove use and hand hygiene. |
| Certified Nursing Assistant (CNA)-C | Certified Nursing Assistant | Observed providing catheter care with improper glove use and hand hygiene. |
| Registered Nurse (RN)-J | Registered Nurse | Verified feeding tube rate was not followed as ordered for resident R35. |
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