Willow Crossing Health & Rehabilitation Center

Inspectors wroteBased on record and interview, the facility failed to follow physician's orders related to hold parameters and obtaining vital signs for cardiac medications for 7 of 21 residents reviewed for quality of care. (Residents 44, 62, 30, 10, 3, 8, and 104)

Inspectors wroteBased on observation and interview, the facility failed to maintain resident records in a private manner related to computer screens being left open with resident information visible for 3 random observations. (Residents 32 and 33)

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure appropriate procedure was followed during providing care for a suprapubic urinary catheter replacement for 1 of 2 residents reviewed for urinary catheters. (Resident 78)

Inspectors wroteBased on record review and interview, the facility failed to have medications available to residents for 2 of 24 residents reviewed for pharmacy services. (Residents 10 and 104)

Inspectors wroteBased on record review and interview, the facility failed to track infections for 3 of 12 residents reviewed for antibiotic stewardship. (Residents 10, 22, and 78)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free of physical and mental abuse by a staff member purposely and forcefully causing a resident to fall from the wheelchair onto the floor. This resulted in the staff member leaving the resident lying on the floor with no assistance, she walked away from the resident going into other resident rooms, while another resident was maneuvering their wheelchair around the resident, and the staff member failed to provide accurate details related to the fall for assessment and follow-up care for 1 of 6 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a major mental illness was appropriately supervised during a physical/mental outburst for 1 of 6 residents reviewed for behavior health services. (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders related to medication hold parameters for 2 of 22 residents reviewed for Quality of Care. (Residents 71 and 5)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and ensure a resident's wound was identified prior to the resident developing a Stage III pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 64)

Inspectors wroteBased on record review and interview, the facility failed to document meal consumption values for 2 of 4 residents reviewed for nutrition. (Residents 55 and 62)

Inspectors wroteBased on observation and interview, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Back 200 Medication Cart and Front 100 Medication Cart)

Inspectors wroteBased on record review and interview, the facility failed to obtain a urinalysis in a timely manner for 1 of 4 residents reviewed for laboratory services. (Resident 36)

Inspectors wroteBased on observation and interview, the facility failed to follow infection control guidelines during dining service for 1 of 2 dining observations. (Residents 102 and 15)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a urinary tract infection received antibiotic treatment in a timely manner for 1 of 3 residents reviewed for urinary tract infections. (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed and for 6 of 15 resident medications reviewed. (Residents 41, 88, 36, 91, 23, and 13)

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served in a sanitary manner for 2 of 4 dining observations and 4 of 5 staff observations. (CNA 3, CNA 17, QMA 16, and CNA 5)

Inspectors wroteBased on observation and interview, the facility failed to to protect resident information related to unlocked computer screens for 4 of 6 random observations for personal privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from mental and physical abuse for 1 of 23 residents reviewed for abuse. (Resident 203)

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders related to hold parameters for a blood pressure medication for 1 of 23 residents reviewed for quality of care. (Resident 48)

Inspectors wroteBased on record review and interview, the facility failed to prevent and follow physician's orders related to a pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 48) The clinical record for Resident 48 was reviewed on 04/16/24 at 1:35 P.M. A Quarterly Minimum Data Set assessment, dated 01/20/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression. A physician's order with a start date of 03/11/24 and discontinue date of 04/18/24, indicated the resident was to wear Blue Prevalon boots at all times. An Initial Pressure Ulcer Assessment form, dated 03/14/24, indicated a suspected deep tissue injury (a purple or maroon area of discolored intact skin due to damage of underlying tissue) was discovered on the right medial heel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate urinary catheter care for a resident with frequent Urinary Tract Infections for 1 of 5 residents reviewed for bladder incontinence care. (Resident 72)

Inspectors wroteBased on interview and record review, the facility failed to implement interventions and complete behavior forms related to dementia care for 1 of 3 residents reviewed. (Resident 69)

Inspectors wroteBased on record review and interview, the facility failed to provide COVID-19 booster immunizations for 8 of 10 residents reviewed for immunizations (Resident F, G, L, M, C, D, E, and H)

Inspectors wrote2. During a continuous observation on 10/25/23 from 11:53 A.M. to 12:23 P.M., of Medication Cart 2, located in the hallway across from the nurse's station, was unlocked. At 11:53 a.m., one nursing staff member was located in the nurses station. At 11:55 a.m. to 12:23 p.m., there were no nursing staff in consistent observation of the unlocked medication cart. Several staff members including, but not limited to, the DON (Director of Nursing), a housekeeper, a maintenance man, a dietary aide, and CNA (Certified Nurse Aide) 10 had walked by the unlocked medication cart. During an interview on 10/25/23 at 12:23 P.M., The DON indicated the medication cart should have been locked if the nurse was not standing by it and medication should not be left sitting out at the nurse's station unattended. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain readily accessible, accurate, and systematically organized resident records for 1 of 12 resident records reviewed. (Resident H)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate wound care related to infection control procedures for 2 of 3 residents reviewed for pressure ulcers. (Resident B and C)