The Legacy at Willow Bend

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility's walk-in refrigerator and freezer on 12/02/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #48) reviewed for catheter care. The facility failed to ensure CNA A and CNA B maintained Resident #48's foley catheter (foley catheter is a common type of indwelling catheter) drainage bag below the bladder level during transfer from wheelchair to bed on 12/03/25. This failure placed residents at risk for the development and/or worsening of urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents (Residents #8) reviewed for feeding tubes. 1. The facility failed to have orders for Resident #8 for the required amount of water for dilution of crushed medications and the amount of water flushes between each medication given via the G-tube. 2. The facility failed to ensure LVN C diluted crushed medication and liquid medication with 30 ml of water and flushed with 15 ml of water after each medication per facility policy while administering Resident #8's medication via G-tube which resulted in the tube becoming clogged during the medication administration. These failures could place residents at risk of medication incompatibility and tube obstruction.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of five residents (Resident #72 and Resident #73) reviewed for pharmacy services. 1. The facility failed to ensure RN G followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #73. 2. The facility failed to ensure RN F followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #72. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer were labeled and had use-by dates. 2. The facility failed to ensure Dietary Server G used appropriate hair restraint in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #8, Resident #3, Resident #29, and Resident #13) of 24 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #8 had his fingernails cleaned and trimmed. 2- Resident #3 had his fingernails cleaned and trimmed. 3- Resident #29 had her fingernails cleaned and trimmed. 4- Personal care and skin care was provided for Resident #13 by trimming his fingernails. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #210) reviewed for respiratory care. The facility failed to ensure Oxygen (O2) in use signage was on Resident #210's doorway. This failure could place residents at risk of not receiving appropriate respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents (Resident #14) reviewed for catheter care. The facility failed to ensure CNA A maintained Resident #14's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag was below the bladder level during wound care on 09/17/24. This failure placed residents at risk for infection .

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for one of one Resident (Resident #9) and one (Nurses Cart Hall 500) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure RN B, responsible for Nurses Cart Hall 500, removed Resident #9's medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication because of possible diminished effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of 12 residents (Resident #23 and Resident #210) observed for infection control. 1. CNA D failed to perform hand hygiene while providing incontinence care to Resident #23. 2. The facility failed to ensure CNA A wore appropriate PPE while providing care to Resident #210 who was on Enhanced Barrier Precaution. These failures placed residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on interviews and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for two (CNA D and CNA E) of 10 employees reviewed for employee files. The facility failed to ensure the facility had a copy of criminal background checks conducted prior to hire for CNA D and CNA E. This failure could place residents at risk for abuse and receiving care from unemployable staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's only medication room and 1 (5300 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- A vial of TB ( Tuberculosis ) serum that was opened and used was dated in the medication room refrigerator. 2- The 5300 Hall medication cart had insulin pen for Resident #13 without an opened date. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Cooks H and I washed hands during lunch meal preparation on 09/13/23. 2. The facility failed to ensure four of six trash cans in the kitchen were covered. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #38) of 19 residents reviewed for comprehensive care plans. 1. The facility failed to develop a care plan for Resident #38's preferences to stay in room and for independent activities in her room. 2. The facility failed to develop a care pan to address Resident #38's pain management. These failures could affect the residents by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #24) of 8 residents reviewed for pharmacy services and for 1 (5400 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The facility failed to ensure medications were not left unsecured at bedside of Resident #24 2- The facility failed to ensure LVN J and LVN N counted controlled drugs on the 09/12/23 night shift/morning shift change. These failures could place residents at risk of not receiving the intended therapeutic benefit of the medication and the risk of not having the medication available due to possible drug diversion Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #22, Resident #40) of 5 residents reviewed for infection control. The facility failed to ensure CMA M disinfected the blood pressure cuff in between blood pressure checks for Residents #22 and #40. This failure could place residents at-risk of cross contamination which could result in infections or illness.