Willow Point Rehabilitation and Nursing Center

Inspectors wroteThe facility identified a census of 29 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 29 residents. The facility had one main kitchen. Based on observation, and interview, the facility failed to ensure staff stored food items by the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food).

Inspectors wroteThe facility identified a census of 29 residents. Based on interviews and record review, the facility failed to implement a policy that prohibited hiring employees found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law when the facility failed to conduct background screening on two employees. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 with two reviewed for accidents. Based on observation, record review, and interview the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, and out of reach of seven cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 10/22/24 at 07:04 AM an inspection of the 100-hall revealed the restorative room was left unlocked and unsupervised. An inspection of the sink area of the room revealed several types of multiple-purpose cleaners in an unlocked cabinet underneath the sink. The bottles contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)24's bed rails were removed as indicated per her most current side rail assessment. The facility additionally failed to ensure that R5, R12, and R17 had safety assessments for the use of side rails that acknowledged the risks from their low air-loss mattresses, risk for entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents. One resident was sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4 had foot pedals on her wheelchair while being pushed. This deficient practice left R4 vulnerable to accidents and injuries due to unmet care needs.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with one sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 18 received supportive care and services to promote and maintain his quality of life when the facility did not implement strategies to allow and promote R18, who had a primary language other than English to communicate his wants, needs, or feelings and promote socialization. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)24's low air-loss mattress was set to the appropriate weight settings per her physician's order and current weight. This deficient practice placed R24 at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure consistent communication between the facility and Resident (R) 15's dialysis center. This deficient practice placed R15 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 29 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow physicians' ordered parameters related to blood glucose monitoring for Resident (R)10 and R15. This deficient practice placed R10 and R15 at risk for delayed treatment of hyperglycemia (greater than the normal amount of glucose in the blood, hypoglycemia (abnormally low blood glucose), and unnecessary medication complications.

Inspectors wroteThe facility identified a census of 31 residents. The sample included three residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on record review and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 33 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to report an allegation of resident-to-resident abuse between R1 and R2 to the State Agency (SA) within the mandated timeframe. This deficient practice placed R2 at risk for unresolved and ongoing abuse.

Inspectors wroteThe facility identified a census of 36 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview the facility failed to ensure staff identified and reported an allegation of physical abuse immediately to the Administrator as required. On 02/09/24 between 10:30 PM to 11:00 PM, Certified Nurse Aide (CNA) N and CNA M provided peri-care to Resident (R)1, a severely cognitively impaired resident who was dependent on staff for assistance with activities of daily living (ADL). As staff rolled R1 towards CNA M, R1 hit CNA M. CNA M allegedly became upset and smacked R1 on the hand. CNA N attempted to report the abuse to Licensed Nurse (LN) G, but CNA M approached, so CNA N ended the conversation and walked away. CNA N mentioned it later to another CNA on shift but did not report it to the Administrator. [...]

Inspectors wroteThe facility identified a census of 45 residents. The facility identified 22 COVID-19 (an acute respiratory illness capable of producing severe symptoms and in some cases death) positive residents on 05/02/23. Based on observations, record review, and interviews, the facility failed to ensure staff exercised appropriate infection control techniques to prevent the transmission of COVID-19 within the facility. The facility failed to disinfect shared equipment used on COVID-19 positive negative residents. The facility failed to accurately identify COVID-19 positive resident rooms, inform staff of COVID-19 positive test results, and implement the required isolation, with the appropriate signage and personal protective equipment (PPE- gloves, gowns, face shields and/or eyeglasses/goggles) designation for those positive residents. [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure cognitively impaired, dependent Resident (R) 38 remained free from abuse when the facility failed to prevent an episode of staff to resident physical abuse. On 05/01/23 at 07:55 AM Certified Nurse Aide (CNA) M brought R38 to the common area in a Broda (special wheelchair with tilt abilities) chair. CNA M then forcefully grabbed R38 by R38's right wrist/forearm multiple times while attempting to adjust R38's shirt and hair, despite the fact the resident raised her right arm in objection to the provision of cares. CNA M held R38's right arm tightly against R38's body and restricted R38's movement while R38 struggled against CNA M's grip. [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three residents reviewed for falls. Based on observation, record review, and interviews, facility failed to identify toileting as a causal factor for falls and implement toileting interventions after R40 experienced falls related to incontinence which resulted in an orbital socket (set of bones that surround the eye) injury. As a result, R40 had another toileting related fall in which she sustained a femur (large bone of upper leg) fracture. Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to identify and implement appropriate, culturally aware, resident-centered interventions to address decreased intake for cognitively impaired Resident (R) 38, who was at risk for weight loss. This deficient practice resulted in a significant, unintended loss of 21.74 percent (%) in four months (between 01/01/23 through 05/04/23) . Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The facility had one main kitchen. Based on observations, record review, and interviews, the facility failed to properly label and store food, failed to store clean dishes inverted, failed to prevent cross-contamination during puree (mechanically altered diet) and mechanical soft (mechanically altered diet) diet preparation, and failed to ensure staff wore hair nets appropriately in the kitchen. This deficient practice had the risk to spread foodborne illness to all affected residents.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for four residents who required assistance from staff to complete the care. This deficient practice placed resident (R)103, R29, R4 and R18 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 45 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends and failed to provide activities for residents in isolation. This deficient practice placed 45 residents at risk for decreased psychosocial wellbeing. Findings Included: - The facility's Activity Calendar for February, March, and April of 2023 revealed the activities schedule for Saturdays and Sundays lacked activities listed on the activity calendar. On 05/01/23 at 08:45 AM Resident (R)46 reported she just got out of isolation due to COVID-19 (highly contagious, potentially life-threatening respiratory virus). She stated she is grateful for being out of isolation because she was bored in her room. [...]

Inspectors wroteThe facility reported a census of 45 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 05/02/23 at 07:38 AM an inspection of the medication cart in the 100 Hall revealed one Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured and one Lispro Flexpen (injectable long-acting hormone which regulates blood sugar) left unsecured on top of the medication storage cart. On 05/04/23 at 01:05 PM an inspection of the Nurses medication storage room was completed. The inspection revealed the medication storage refrigerator temperature log was not being completed. An open cup pudding labeled March 2023 was inside the refrigerator. [...]

Inspectors wroteThe facility identified a census of 45 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: The facility failed to ensure cognitively impaired, dependent R38 (moderately cognitively impaired resident) remained free from abuse when the facility failed to prevent an episode of staff to resident physical abuse. (Refer to F600) The facility failed to ensure staff effectively communicated with R38 (moderately cognitively impaired resident the uses gestures and sign language to communicate) during ADL care. [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with five residents sampled for immunization review. Based on record review and interviews, the facility failed to obtain pneumococcal (infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination signed consents or declinations for Resident (R) 4, R41, and R44 and the facility failed to administer pneumococcal vaccination after signed consent was obtained for R29. This deficient practice had the risk for physical complications and the risk to spread illness among residents, a high-risk population.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to assess and document resident-centered dietary and mealtime preferences for Resident (R) 18. This deficient practice had the risk for weight loss, and declines in psychosocial well-being and independence for R18.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents. Based on interview and record review the facility failed to issue the Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123, which contained the required information for Resident (R) 45. This failure placed the resident at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to complete a baseline care plan for R103, which placed him at risk of impaired care related to unidentified or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for discharge. Based on record review and interviews, the facility failed to ensure active discharge planning occurred for Resident (R) 51. This deficient practice had the risk for miscommunication of discharge goals and missed services for R51.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents, with one resident reviewed for discharge. Based on record review and interviews, the facility failed to complete a discharge summary including a recapitulation of stay for Resident (R) 51. This deficient practice placed the resident risk for miscommunication of services received during a stay in the facility and of post discharge care needs.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 13 residents with four reviewed for maintaining activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to ensure staff effectively communicated with R38 during ADL care. This deficient practice placed R38 at risk for a decline in her ADLs and decreased psycho-social wellbeing. Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for treatment of pressure injuries. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 18, who was on an antibiotic (medication used to treat bacterial infections) for a wound infection. This deficient practice placed R18 at risk of wound worsening and complications related to infections.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)40, and R6. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses muscle weakness, history of falls, dementia (progressive mental disorder characterized by failing memory, confusion), reduced mobility, cognitive communication deficit, anxiety (progressive mental disorder characterized by failing memory, confusion), and left femur fracture (broken bone in left upper leg). [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) in a sanitary manner for Resident (R) 33. This deficient practice placed R33 at increased risk to develop a respiratory infection.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide adequate dementia care and services for Resident (R) 38 (a cognitively impaired resident displaying dementia related symptoms). This deficient practice placed R38 at risk for preventable injuries and accidents as well as impaired quality of life. Findings Included: [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were followed up for Resident (R) 33 related to an antihypertensive medication (class of medication used to treat hypertension (high blood pressure) which was held, and the physician was not notified. The facility failed to follow CP recommendations for antihypertensive medication administered outside of physician ordered parameters for R33 and R4. The facility also failed to notify the physician of blood sugars outside of ordered parameters for R33. This deficient practice had the potential for unnecessary medication use and possible adverse consequences and side effects.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow physician orders for Resident (R) 33's antihypertensive medication (class of medication used to treat hypertension (high blood pressure)), when staff held the medication and did not notify the physician, as ordered The facility failed to follow the consultant pharmacist recommendations for antihypertensive medication administered outside of physician ordered parameters for R33 and R4. The facility also failed to notify the physician of blood sugars outside of ordered parameters for R33. This deficient practice had the potential for unnecessary medication use and possible adverse consequences and side effects.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed to obtain signed consents or declinations for COVID-19 vaccinations for Resident (R) 44. This deficient practice had the risk for unwarranted physical complications and the risk to spread illness among residents, a high-risk population.

Inspectors wroteThe facility identified a census of 45 residents. Based on observation, record review, and interviews, the facility failed to post and provide daily nursing staff numbers and hours and failed to maintain the posted daily nurse staffing data for the required 18 months. This deficient practice had the risk for miscommunication regarding resident care and staffing.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of the residents residing in the facility. Findings Included: - On [DATE] at 11:35 AM, Resident (R)6, who was alert and oriented, reported the facility staff tell him they did not have enough staff to provide him with his scheduled showers three nights a week on Monday, Wednesday, and Fridays. The resident reported he was lucky to get one bath a week. He stated the staff had to use a full body lift to transfer him and there has to be two staff present while they use the full body lift and they only have one CNA on each of the three halls and sometimes they did not even have that. [...]

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, interview and record review, the facility failed to ensure sanitary room cleaning in a manner to prevent the spread of infection. The facility failed to track and trend infections and causative organisms on an ongoing consistent manner (December 2020, January 2021, February 2021, July 2021, August 2021, and September 2021) to evaluate for the prevalence of organisms causing infections amongst the residents.

Inspectors wroteThe facility reported a census of 53 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship were followed by nursing staff to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance for the residents of the facility.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility for resident rooms on two of the three resident halls.

Inspectors wroteThe facility reported a census of 53 residents and identified nine with restorative nursing programs. The 18 residents sampled included one other resident (not identified by the facility) Resident (R) 19 reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide the planned and ongoing restorative nursing services to the one sampled resident and the nine identified residents including R5, R27, R37, R21, R25, R30, R41, R48, and R54, to maintain as much functional range of motion ability as possible.

Inspectors wroteThe facility reported a census of 53 residents and the facility contained two medication rooms. Based on observation, record review, and interview the facility failed to ensure an accurate system to reconcile the discontinued medications from any residents with discontinued medications.

Inspectors wroteThe facility reported a census of 53 residents with 18 residents included in the sample, including one resident reviewed for accommodation of needs. Based on interview, observation and record review, the facility failed to ensure functional accommodation of needs for one Resident (R)19, regarding anti-tip brakes (brakes applied to wheelchair to help prevent falls) on his wheelchair.

Inspectors wroteThe facility reported a census of 53 residents with 18 sampled which included one resident reviewed for choices. Based on observation, interview, and record review the facility failed to provide choices for dependent Resident (R)6 related to his preferences for frequency, time, and type of bath.

Inspectors wroteThe facility reported a census of 53 residents, with 18 residents sampled. Based on observation, interview and record review, the facility failed to develop an individualized comprehensive plan of care for two of the 18 sampled Residents (R)18, regarding toileting and R 19, regarding Activities of Daily Living (ADL).

Inspectors wroteThe facility reported a census of 53 residents with two sampled for discharge. Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, reconciliation, and disposition of the medications for resident (R)57.

Inspectors wroteThe facility reported a census of 53 residents with 18 residents sampled, including five residents reviewed for Activities of Daily Living (ADL). Based on interview, record review, and observation, the facility failed to provide necessary assistance to maintain cleanliness for three of the five sampled dependent Residents (R)6, R 18, and R 19, regarding bathing.

Inspectors wroteThe facility reported a census of 53 residents with 18 residents sampled which included one resident reviewed for pressure ulcers care and treatment. Based on observation, interview and record review the facility failed to ensure resident (R)6 with pressure ulcers received necessary treatment and services, to promote healing, and prevent infection or decline in the resident's pressure ulcers.

Inspectors wroteThe facility reported a census of 53 residents with 18 residents sampled, which included five residents reviewed for indwelling catheter and incontinence care/treatment. Based on observation, interview, and record review, the facility failed to provide catheter care/and treatment to prevent infection for two residents with indwelling catheters Residents (R)6 and R 9. The facility also failed to provide necessary care and treatment to maintain as much bladder function as possible for two sampled incontinent residents, R18 and R19.

Inspectors wroteThe facility reported a census of 53 with 18 residents sampled for review including one resident reviewed for tube feeding. Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent complications including aspiration pneumonia and metabolic abnormalities for the one sampled resident with tube feedings, Resident (R) 51.

Inspectors wroteThe facility reported a census of 53 residents, with 18 residents selected for review including one resident reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to provide adequate respiratory services with the failure to label the oxygen tubing when changed, failure to label the distilled water container when opened and store it appropriately. These practices increased the risk for Resident (R)11 of developing a respiratory infection.

Inspectors wroteThe facility reported a census of 53 resident with 18 residents sampled which included five residents for unnecessary medications. Based on interview and record review the facility failed to act upon the pharmacist's recommendation to resolve identified irregularities for Resident (R)16, related to insulin and antihypertensive medication.

Inspectors wroteThe facility reported a census of 53 resident with 18 residents sampled which included five residents for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the resident's drug regimen was free of unnecessary medications related to the administration, monitoring for effectiveness, and side effects of insulin and antihypertensive medications as ordered by the physician for Resident 16.

Inspectors wroteThe facility reported a census of 53 residents with 18 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure Resident (R)9 was kept free from unnecessary medications, by not reducing the order for Fluoxetine (an antidepressant medication used to treat depression), as ordered, in a timely manner.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, interview, and record review, the facility failed to post Nurse Staffing information for Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, the resident census, and the total number of actual hours worked by each category, daily as required.