Willis Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents viewed for infection control. - LVN B did not wear appropriate PPE when performing wound care on Resident #1, when he was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan or the residents' goals and preference for 1of 2 residents (Resident #34) reviewed for respiratory care. Resident #34 did not receive oxygen at the rate ordered by the physician. This failure could place residents who receive oxygen therapy at risk of receiving the incorrect rate of oxygen and a decline in health.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for one Resident's bathroom (Resident #19) out of 22 bathrooms and one hallway out of four hallways reviewed for pests.-The facility failed to ensure the building was free of cockroaches. A cockroach was found on the Surveyor's clothing while standing in a hallway during medication pass. A cockroach was observed in Resident #19's bathroom on two separate occasions. These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 unit refrigerators. 1. The facility failed to ensure foods were labeled in order to identify the contents and dated when opened. 2. The facility failed to ensure food was properly stored in designated areas at all times. These failures could place residents who ate food from the unit refrigerator at risk of food borne illness and disease. Findings Included: Observation of the unit refrigerator located in the medication room [ROOM NUMBER]/25/24 at 8:50 AM revealed the following: 1. A clear plastic container with a green top which contained a yellow substance that appeared to be pudding had no label and was did not have the date it was prepared. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for accidents. -The facility failed to safely transfer Resident #1 and prevent injury during a mechanical lift transfer that resulted in Resident #1 sustaining a laceration to her left leg requiring her to be sent to the hospital This failure could place resident at risk for accidents, injuries, and hospitalization. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Intake ID #433231 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart #6) of four medication carts reviewed for storage of medications. Nurse Cart #6 had a punctured protective seal on the back of a narcotic medication blister pill card. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 5 (Resident #5) residents observed for privacy and dignity in that: -The facility failed to pull the privacy curtain in Resident #5's room during incontinent care. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 5 residents (Resident #1) reviewed for activities of daily living. -The NF failed to provide proper perineal/incontinent care for Resident #1. This failure placed resident at risk for UTI's (urinary tract infections), sepsis (presence of harmful bacteria in the blood), and unwanted hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to restore, if possible, oral skills and to prevent complication of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 of 5 residents (Resident #1) reviewed for quality of care. -CNA failed to inform the nurse to stop Resident #1's continuous gastrostomy feedings while providing incontinent care with resident head of bed flat. The failure placed resident at risk for aspiration, pneumonia, and unwanted hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 of 5 (Resident #1) reviewed for infection control. -NA C failed to place soiled linen in bag during incontinent care, instead of placing the soiled linen on floor. This failure placed residents at risk for cross contamination, spread of infections, and decrease in quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to honor the rights of the resident to self-determination and to make decisions about their care for 1 of 6 residents (Resident #25) reviewed for resident rights. The facility failed to accommodate Resident #25's right to refuse her therapeutic diet. This failure could place residents at psychosocial and emotional risk by not having their rights upheld.

Inspectors wroteBased on interview, observation, and record review the facility failed to honor the right of the resident to participate in the planning process and revision of the care plan to for 1 of 6 residents (Resident #25) reviewed for care plan. The facility failed to accommodate Resident #25's right to refuse her therapeutic diet and include accommodations in the resident's care plan. This failure could place residents at risk for not having their right to participate in the planning process of their individual person-centered plans of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance to professional standards of practice and the resident's person-centered care plan for 1 of 12 residents (Resident #5), in that: - Resident #5's laceration on foot failed to be reported to the Wound Care Nurse and treated. This failure could place residents at risk of not receiving adequate care in a timely manner.