Willow Care Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 68. The facility did not provide a dietary cleaning rotation or food storage policy. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for seven residents (Residents #80, #81, #83, #84, #85, #86, and #87) out of a sample of eight residents, and failed to complete a final accounting of resident personal funds within 30 days of discharge for six residents (Residents #88, #89, #90, #91, #93, and #94) out of a sample of seven residents. The facility also failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security Income (SSI) limit ($6,068.80) or when the resident's account was over the SSI limit. This affected one resident (Resident #43) out of a sample of 17 residents reviewed who received Medicaid benefits. The facility census was 68. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility also failed to ensure correct antibiotic therapy duration for one resident (Resident #73) out of two sampled residents. The facility census was 69. Review of the facility's policy titled, Infection Prevention and Control Program, revised October 2018, showed:- Infection prevention and control program is developed to address the facility specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in the proper position for one resident (Resident #45) out of one sampled resident. The facility census was 68. Review of the facility's policy titled, Urinary Catheter Care, dated December 2025, showed:- Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #45's medical record showed:- admitted on [DATE];- Diagnoses of urinary tract infection (UTI - a bacterial infection of the bladder and associated structures), benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate), and retention of urine. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #15 and #56) out of three sampled residents. The facility census was 72. The facility did not provide a policy regarding SNF ABN forms. 1. Review of Resident #15's medical record showed: - The resident was discharged from skilled Medicare services on 08/16/24, and remained in the facility; - No documentation the resident and/or the representative received a SNF ABN; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for three residents (Residents #15, #34, and #70) out of six sampled residents. The facility's census was 72. The facility did not provide a policy for transfer/discharge notifications. 1. Review of Resident #15's medical record showed: - The resident transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE] and 05/13/24. 2. Review of Resident #34's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for four residents (Residents #22, #42, #52, and #63) out of 19 sampled residents and one resident (Resident #42) outside the sample. The facility census was 72. The facility did not provide a policy related to the accuracy of the MDS assessments. 1. Review of Resident #22's medical record showed: - Diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for two residents (Residents #9 and #20) out of 19 sampled residents. The facility census was 72. Review of the facility policy titled, Policy and Procedure Physician Orders, revised 07/01/17, showed: - Written/faxed orders require a physician signature in order to constitute a valid order; - The order should be clear, concise and contain the required components; - Orders that are missing required components, illegible or are unclear, will be clarified prior to implementation; - The licensed nurse is required to record the order in Point Click Care (PCC), the Physician Order Sheet (POS) and on the appropriate Medication Administration Record (MAR)/ Treatment Administration Record (TAR). 1. Review of Resident #9's medical record showed: - admission date of 01/12/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for placement and care of an indwelling catheter (a tube inserted into the bladder to drain urine) for one resident (Resident #323) out of two sampled residents. The facility census was 72. Review of the facility policy titled, Policy and Procedures Physician Orders, dated 07/01/17, showed: - An order must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; - Physician's orders must be documented clearly in the medical record. Review of the facility policy titled, Catheter Care, Urinary, dated September 2014, showed: - Notify the physician or supervisor if the catheter is accidentally removed. 1. Review of Resident #323's medical record showed: - Date of admission [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #9) out of one sampled resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 72. Review of the facility policy titled, Pain Assessment and Management, dated March 2020, showed: - The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; - The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for two residents (Resident #6 and #9) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 72. Review of the facility policy titled, Trauma Informed Care, dated March 2019, showed: - The purpose is to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma; - Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two out of two sampled Certified Nurse Assistants (CNA) (CNA D and CNA E). The facility's census was 72. Review of the facility's policy titled, In-Service Training Program, Nurse Aide, revised 08/2010, showed: - Each nursing assistant must attend, at a minimum, twelve hours of continuing education annually. 1. Review of CNA D's in-service record showed: - A hire date of 07/28/21; - A total of three hours and 30 minutes of annual in-service training for July 2023 through July 2024; - Less than twelve hours of in-service education for July 2023 through July 2024. 2. Review of CNA E's in-service record showed: - A hire date of 04/12/13; - A total of three hours and 30 minutes of annual in-service training for April 2023 through April 2024; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 73. Record review of the CDC (Centers for Disease Control and Prevention) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated 03/25/2021, showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received a written notice of the bed-hold policy upon transfer when staff failed to provide three residents (Residents #24, #32 and #39) written notices of the facility's bed-hold policy when transferred to the hospital. The facility census was 73. Record review of the facility's policy entitled Bed-Holds and Returns, revised March 2017, showed the following information: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Residents may return to and resume residence in the facility after hospitalization as outlined in this policy; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff did not provide activities scheduled, did not provide a calendar with times of activities noted, and did not track attendance of activities to evaluate if activities needs were being met for four residents (Resident #9, #25, #59, and #65). The facility's census was 73. Record review of the facility's policy titled, Group Programs and Activities Calendar (Revised January 2011), showed the following: -Group activities are available in this facility and an activities calendar is completed to inform residents, families and staff of the activity opportunities available; -The activities calendar states all activities available for the entire month; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light cords were available to residents at all times when staff stored emergency call light pull cords where residents could not access the pull cord to call for staff assistance in the bathrooms of seven residents (Residents #15, #25, #30, #34, #41, #59, and #73). The facility census was 73 residents. Review of a facility policy and procedure entitled Answering the Call Light (Revised March 2021) showed the following information: -The purpose of the procedure is to ensure timely responses to the resident's requests and needs; -Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Ask the resident to return the demonstration; -Explain to the resident that a call system is also located in his/her bathroom; [...]