Willow Creek Retirement Center

Inspectors wroteBased on record review, facility policy review and interviews, the facility failed to ensure that a resident was protected from physical abuse when the Resident Representative (RR) struck the resident in the face. for one (1) of seven (7) sampled residents. (Resident #2). Findings Included:Record review of the facility policy Abuse, Neglect and Exploitation with a revision date 5/25/24, revealed .Mistreatment means inappropriate treatment or exploitation of a resident. Physical Abuse includes, but is not limited to hitting, slapping. It also includes controlling behavior through corporal punishment. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves. III. Prevention of Abuse. E. [...]

Inspectors wroteBased on observation, record review, facility policy review and interviews, the facility failed to ensure that residents were free from the misappropriation of resident property and exploitation when a licensed nurse signed for and took scheduled medication delivered by the pharmacy for one (1) of four (4) residents reviewed for medication administration. (Resident #1). Findings Included:Record review of the facility policy, Abuse, Neglect and Exploitation with a revised date of 05/25/24 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices during resident care by failing to perform hand hygiene during incontinent care (Resident #66), failing to implement Enhanced Barrier Precautions during catheter care (Resident #13), and contaminating environmental surfaces with soiled gloves during wound care (Resident #36) for three (3) of four (4) care observations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of communication needs when a functioning bedside telephone was not provided for one (1) of (18) sampled residents. Resident #9.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, and homelike environment when the air conditioning vent in the resident's room contained excessive dust and debris for one (1) of (18) sampled residents. Resident #9.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement a resident's comprehensive care plan intervention related to Enhanced Barrier Precautions for one (1) of (18) care plans reviewed. Resident #13.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a Foley (indwelling catheter) was properly secured with a leg strap to prevent catheter movement and trauma for one (1) of two (2) residents reviewed for urinary catheters. Resident #13.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored securely when medications were left unattended at a resident's bedside for one (1) of two (2) medication storage observations. Resident #33.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure proper infection control practices related to hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube site care during an annual recertification survey on 11/7/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F880Findings include:A review of the facility's policy, Quality Assurance Performance Improvement, revised 5/7/18, revealed .Policy: [...]

Inspectors wroteBased on record review, interview and facility policy review the facility failed to provide necessary behavioral services by qualified staff to ensure residents' dignity, privacy, and safety and failed to promote mental and psychosocial well-being for five (5) of (5) residents. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and wound care for two (2) of (19) sampled residents. Residents #14 and #30 Findings Include: A review of the facility's policy titled Hand Hygiene, dated 06/12/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . If your task requires gloves, perform hand hygiene prior to donning gloves, and sanitize or wash hands after removing gloves . Resident #14 On 11/06/24 at 1:08 PM, during an observation of wound care, Licensed Practical Nurse (LPN) #1/Wound Care Nurse, performed a dressing change on Resident #14's right elbow. [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the comprehensive care plan interventions were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 19 care plans reviewed. Resident #30 Findings Include: A review of the facility's policy titled Care Plans, dated 02/20/20 revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provides care . PROCEDURE: . 6. Staff approaches are to developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the physician orders were followed related to the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of (19) sampled residents. Resident #30. Findings Include: A review of the facility's policy titled, Dressing Change, policy (undated) revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 11/06/24 at 1:25 PM, during an observation of PEG tube site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while Resident #30's feeding pump was infusing Glucerna 1.2 at 50 cubic centimeters (cc) per hour. LPN #1 then proceeded to clean the PEG site with gauze in a circular motion without drying the site afterward. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to prevent significant medication errors for one (1) of six (6) residents observed for medication administration. Resident #9 Findings Include: A review of the facility's policy titled Medication Administration Guidelines, (undated), revealed, Medications are administered as prescribed .18. Prior to administration, the medication and dosage schedule on the resident's MAR/TAR or EMAR/ETAR is compared with the medication label. Information on the medication should be checked against the MAR/ETAR at least three times during the med preparation and administration process . During an observation on 11/04/24 at 8:35 AM, Licensed Practical Nurse (LPN) #3 pulled medications for Resident #9. [...]

Inspectors wroteBased on interviews, record review, and facility investigation review, the facility failed to provide adequate supervision to prevent an accidental coffee burn for one (1) of the four (4) sampled residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide care and services to promote healing and prevent infection for one (1) of four (4) residents that required wound care. Resident #2 Findings Include: Record review of the facility policy titled DRESSING CHANGE, (undated), revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 5/23/24 at 3:50 PM, an observation of Resident #2 revealed she was lying on her back in bed. The resident's incontinence brief was wet and had fecal matter present. There were two small open areas on her sacral area, with no bandage present. On 5/23/24 at 4:55 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was assigned to the care of Resident #2 on 5/23/24. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of three (3) sampled residents with pressure ulcers. (Resident #2)

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide care and services for a resident with an indwelling urinary catheter in a manner to prevent the potential for a urinary tract infection (UTI) for one (1) of two (2) sampled residents with indwelling urinary catheters. (Resident #6)

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to maintain a clean ice machine for the residents as evidenced by white, red, and black residue build up on the inside and outside of the ice machine, observed on one (1) of five (5) kitchen tours.

Inspectors wroteBased on resident and staff interviews, record reviews, and facility policy review, the facility failed to document and act promptly to resolve grievances and recommendations from Resident Council Meetings for six (6) of 6 months of resident council meeting minutes reviewed.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to honor the resident's right to make choices, as evidenced by residents having to remain out of bed during mealtimes for two (2) of four (4) residents reviewed for choices.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to shave a resident that required assistance with shaving for one (1) of 18 residents reviewed for Activities of Daily Living.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide appropriate catheter care of for one (1) of three (3) residents reviewed for a catheter care. Resident #29 Finding's include: Review of the facility policy titled, Catheterization Policy, with no revision date, revealed, . Reminders -Tubing and bag should be properly positioned below hip level . An observation on 2/21/23 at 8:45 AM, revealed Resident #29 lying in bed with a nephrostomy bag attached to the head of the bed on her right side. The head of the bed that was elevated to approximately 30 degrees. An interview on 2/22/23 at 8:40 AM, with Certified Nurse Assistant (CNA) #2, revealed that Resident #29 gets turned every two hours. The CNA stated the urine catheter bag does not affect her turning, because it always stays at the head of the bed. [...]

Inspectors wroteBased on interviews, record reviews and facility policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were discontinued after 14 days, for one (1) of six (6) residents reviewed for unnecessary medications.