Willow Park Health Care Center

Inspectors wroteOn 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure a comprehensive care plan was developed for Resident #9 to prevent an elopement on 07/27/25. Resident #9's cognition was severely impaired with a BIMS score of 2. Resident #9 had four elopement assessments which identified Resident #9 as a high risk for elopement. Resident #9 had several exit seeking attempts and elopements during a three-month period. After each elopement or attempted elopement, the resident was placed on one-on-one supervision. Resident #9's care plan was not updated with one-on-one supervision, and there was no documentation of one-on-one supervision was ongoing to prevent elopement. CNA #2 stated they did not know what was supposed to happen when a resident had multiple elopement events. [...]

Inspectors wroteOn 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure Resident #9 had adequate supervision to prevent elopements on 07/11/25, 07/27/25, 09/04/25, and 09/30/25. Resident #9's cognition was severely impaired with a diagnosis of dementia. Resident #9 had three elopement assessments that placed them at high risk for elopement. Resident #9 had two episodes of exit seeking where staff redirected them and brought them back into the facility, and four additional elopements where staff were not aware the resident was gone from the facility. The facility failed to ensure adequate supervision to protect Resident #9 from elopement. Direct Care staff were not aware the resident was at risk for elopement, and stated there was a lack of communication and training. On 01/14/26 at 5:52 p.m., the OSDH was notified and verified the existence of an IJ situation. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate assistance to prevent a lift accident for 1 (#3) of 3 residents reviewed for accidents. The administrator reported 78 residents resided at the facility.

Inspectors wroteOn 10/03/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #38, who had been assessed to require supervision and a smoking apron when smoking, was provided adequate supervision. A care plan intervention, updated 01/31/24, documented Resident #38 required staff supervision with smoking and the use of a smoking apron. A smoking assessment, dated 02/15/24, documented Resident #38 was safe for smoking with supervision and use of a smoking apron. An incident report, dated 04/19/24, documented an unwitnessed incident. The report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. The incident report documented two small burns to the left side of the resident's face and under their left ear. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure advance directive acknowledgement forms were completed for two (#10 and #24) of 18 sampled residents reviewed for advance directives.

Inspectors wroteBased on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a Level II PASARR evaluation for three (#9, 38, and #60) of three sampled residents reviewed for PASARRs. The administrator identified 78 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. enhanced barrier precautions were implemented for two (#69 and #78) of three sampled residents observed during wound care; b. enhanced barrier precautions were implemented for one (#69) of one sampled resident observed during Foley catheter care; and c. contact precautions were implemented for one (#49) of one sampled resident observed for transmission-based precautions. The ADON #2 identified one resident required TBP. The regional consultant identified 19 residents required enhanced barrier precautions. The administrator identified 78 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of neglect was reported to the State Agency (OSDH) for one (#38) of one sampled resident reviewed for abuse. The administrator identified 78 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge summary, to include a recapitulation of the resident's stay, for two (#4 and #5) of two residents reviewed for discharge. The administrator reported a census of 78 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide supervision to prevent elopement for one (#5) of one resident reviewed for elopement. The DON reported three residents who exhibited exit-seeking behaviors and no incidents of elopement.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician, per physician orders, for systolic blood pressure readings out of parameters for one (#13) of five residents reviewed for physician orders. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete performance reviews for CNAs as required annually. The DON reported 15 CNAs had been employed and worked in the facility for over one year.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility remained free of flies. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to transmit a resident assessment as required for one (#76) of 22 resident assessments reviewed for timely transmission. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a person-centered care plan for a resident who required respiratory treatments for one (#31) and failed to complete smoking safety assessments quarterly for one (#42) of 19 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility and the DON identified 22 residents who required smoking safety assessments.

Inspectors wroteBased on record review and interview, the facility failed to have a process in place, to ensure medications were administered as ordered, for one (#85) of six sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure required staff in-service training was provided to address dementia management, pain recognition, first aid procedures, CPR, and the Heimlich maneuver. The Resident Census and Conditions of Residents form, dated [DATE], documented 92 residents resided in the facility.

Inspectors wroteBased on record review, observation and interview, the facility failed to implement comprehensive care plan interventions for three (#9, #24, and #45) of five residents reviewed for the use of unnecessary meds. The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plans were updated for two (#9, and #44) of 14 residents whose care plans were reviewed. The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the physician or facility staff acted upon pharmacist recommendations of findings identified during monthly medication regimen reviews for four (#9, 24, 44, and #45) of five residents reviewed for unnecessary medications. The Resident Census and Census of Conditions, dated 11/15/22, documented 78 residents resided in the facility.