Willow Park Rehabilitation and Care Center

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 kitchen reviewed for food and nutrition services and 2 of 2 resident nourishment rooms reviewed for sanitary conditions.1. The facility failed to ensure a trash barrel containing raw egg shells and other waste was covered in the kitchen.2. The facility failed to ensure meat was not being thawed in a sink on the morning of 6/14/2026.3. The facility failed to ensure foods were in sealed containers and were labeled and dated in the walk-in refrigerator and the non-perishable food storage room on the morning of 6/14/2026.4. The facility failed to ensure dietary employees' food and drinks were not stored in a resident food refrigerator in the kitchen.5. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the residents' medical, nursing, mental, and psychosocial needs, for 9 of 18 residents (Residents #4, #5, #8, #9, #35, #46, #65, #69, and #77 ) reviewed for care plans.1. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #4's hearing difficulty.2. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #5's skin condition and skin tears.3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 7 residents (Residents #4, #7, #8, #69, and #72 ) reviewed for respiratory care. 1. The facility failed to ensure oxygen tubing for Residents #4, #7, #8, #69, and #72 was changed weekly, dated, and kept in a bag when not in use. 2. The facility failed to ensure Residents #7, #69, and #72's nebulizer masks were dated or kept in a bag while not in use.3. The facility failed to ensure Residents #4 and #7 had the needed liquid for proper humidification when oxygen was in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to ensure residents have the right to formulate an advanced directive for 1 (Resident #10) of 18 residents reviewed for advanced directives. 1. The facility failed to ensure that the electronic medical record dashboard and order reflected Resident # 10's wishes for DNR status. This deficient practice could place residents at risk of not having their wishes known and potentially receiving CPR during an emergency.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 residents care was reviewed. Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 (Resident #30, Resident #52) residents care was reviewed. Resident #30 and Resident #52 had handwritten signs placed in the view of residents, staff and visitors that revealed personal medical information. These failures could affect residents by contributing to poor self-esteem, lack of information, and unmet needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to environment free accident hazards for 2 of 2 residents reviewed. Based on observation, interview, and record review the facility failed to environment free accident hazards for 2 of 2 (Resident #65 and Resident #30) reviewed for accident hazards in that:The facility failed to maintain an environment free from accident hazards for Resident #65 who had a sharp edge on broken bed remote in their room. The facility failed to maintain an environment free from accident hazards for Resident #30 who had a used syringe left on bedside nightstand in their room. These failures had the potential to result in injury and exposure to bloodborne pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 2 of 4 residents (Residents #7 and #77) reviewed for medication administration, in that:1. The facility failed to administer Resident #7's medications in a timely manner and withing the facility's medication window for administration on 6/15/2026, which included Keppra (a medication used to treat seizures), Midodrine (a medication used to treat low blood pressure), Eliquis (a blood thinning medication), Fludrocortisone Acetate (a medication used to treat low blood pressure), Loratadine (a medication used to treat allergies), Vitamin D3 (a medication used to treat muscle weakness), Lyrica (a medication used to treat nerve pain), and Potassium Chloride (a medication used to treat low potassium).2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts (Medication Carts Hall 300 and Hall 400) reviewed for medication storage. The facility failed to ensure medication carts were secured and locked. This failure could place residents at risk for drug diversion.

Inspectors wroteBased on observation, interview , and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #80) of three residents (Resident #80) reviewed for infection control practices. CNA M failed to perform proper hand hygiene including which included changing gloves while providing incontinence care to Resident #80 on 06/15/26. This failure could place residents at risk for the spread of infection. Findings Included: Record review of Resident #80's face sheet, dated 06//17/26, revealed a 79- year- old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. MA A failed to perform hand hygiene while administering medication to Resident #1 MA A stuck her bare hands into a pill bottle of buspirone 15 mg which contained multiple pills. These failures could affect the residents by placing them at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 2 of 2 nurse's stations (Hall 100/200 station and Hall 300/400 station). Resident's emergency call light was not audible at either the Hall 100/200 or Hall 300/400 nurse's stations. This failure placed residents at risk of not receiving timely care/assistance, falls, fall related injuries, head trauma, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #12 and Resident #13) of thirteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #12 and Resident #13 on 05/22/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers/wounds. The RN B failed to provide wound care for Resident #3's unstageable pressure ulcer to the right buttock and unstageable pressure ulcer to her right lateral foot on the date of 04/12/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 15 employees (MM and CNA B) reviewed for employability. The facility failed to ensure record of criminal history check and/or an EMR/NAR check prior to offering employment were maintained. These findings placed residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu for 1 of 1 lunch meals observed. 1. The facility failed to ensure a sufficient amount of vegetables were prepared for residents on a regular diet. 2. The facility failed to ensure residents who were on a regular diet received vegetables that were not pureed. These failures could place residents at risk for dissatisfaction, poor intake, altered nutritional status, choking, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct an accurate assessment for 1 (Resident #47) of 18 residents reviewed for assessments. The Facility failed to ensure Resident # 47 most recent MDS dated [DATE] was accurately completed with Resident's hospice status, who was receiving hospice care. These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 18 residents (Resident #74) reviewed for accuracy of records, in that: The facility failed to document in Resident #74's weekly skin assessment dated [DATE], that Resident #74 had a pressure ulcer to her right buttocks discovered on 04/02/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 (Resident #3) of 10 residents reviewed for resident call system. The facility failed to provide a working communication system on 10/01/2024 that was easily at reach and that would allow Resident #3 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #1) of 4 residents reviewed for discharge requirements. The facility failed to ensure Resident #1 was provided a discharge in writing with appropriate reason for the necessity of discharge. This failure placed residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmission for one of four residents (Resident #1) reviewed for discharge planning. 1. The facility failed to implement discharge plan for Resident #1 who was admitted on [DATE] until the day he was discharged on 09/25/2024 . 2. The facility failed to notify the Ombudsman of Resident #1's discharge. 3. The facility failed to notify Resident #1's physician of the discharge. These failures could place residents at risk of not having their care needs addressed after discharge.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 21 of 21 days reviewed for required postings. The facility failed to ensure the daily staffing information was posted in a prominent location on 10/02/2024. This failure could place residents, their families, and visitors at risk of not knowing how many staff are currently working to provide care on all shifts. Findings Included: During an observation on 10/02/2024 at 11:40 AM, the daily staffing posted in hallways was dated 09/11/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 3 of 4 supper meals planned during the 4 day survey time frame. A menu substitution was hand-written on the Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Monday's 2/12/24 supper meal. The substitution was not recorded on the Menu Substitution Sheet. The Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Wednesday's 2/14/24 supper meal was partially substituted with the menu for Thursday's 2/15/24 supper meal due to the main entrée of chicken and dumplings not being prepared according to the planned menu for 2/14/24. This failure placed the residents at risk for not receiving meals adequate to meet their nutritional needs and a decline in nutritional health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at safe and appetizing temperatures during observation of the preparation of one of one meal. The planned Wednesday supper menu for 2/14/24 was substituted and potato salad and sliced red beets were not prepared in advance to ensure they were served at 41 degrees F or below. This failure placed residents at risk for receiving food that was not at a palatable temperature and foodborne illness.

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 one of one kitchen, in that: The top exterior surface of the ice machine was soiled with dust build-up and had a plastic ice scoop on it without being in a protective holder. A stainless steel shelf was soiled with spilled spices. Cooking utensils and pans were suspended in the air from a frame and their sanitized food surfaces were exposed to the air. The nonperishable food storage room had a bulk storage container with brown sugar with a plastic scoop in it and an opened package of waffle mix had been placed in a resealable plastic bag but was not labeled or dated. The door to the walk-in refrigerator was left open during the evening meal preparation on 2/14/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessments accurately reflected the residents' status for 2 of 4 residents (Residents #2 and #14) whose records were reviewed for accurate assessment of nutritional status, in that: 1- Resident #2 had a significant weight loss of 12.86 % in a 6-month time frame, going from 171 pounds during July 2023 to 149 pounds during January 2024. Resident #2's annual MDS assessment, dated 7/20/2023 documented a weight of 171 pounds, and the quarterly MDS assessment, dated 1/01/2024 documented a weight of 149 pounds with no weight loss of 10% or more during the past 6 months. 2- Resident #14 had a significant weight loss of 14.29% in a 5-month time frame, going from 157.5 pounds during August 2023 to 135 pounds during January 2024. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition for 1 of 8 residents (Resident #51) reviewed for mental illness, intellectual disability, or developmental disability. The facility failed to complete a PL1 with addendum form -1012 when Resident # 51 received a new diagnosis for Bi-Polar Disorder, current episode manic severe with Psychotic features added on 11/18/2023. This failure placed resident at risk of mental health needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 2 residents (Resident #57) reviewed for ADLs. The facility failed to provide showers consistently for Resident #57. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status.

Inspectors wroteBased on , interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs on 4 of 4 medication carts. The Change-of-Shift Record of Control Substance Log for the 100/200, 400/500 medication carts were missing signatures. These failures could place residents receiving medications in the facility at risk for a drug diversion.