Willow Ridge Healthcare

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. Surveyor observed a scoop left in the flour storage bin. Missed opportunities for litmus testing of sanitation solution (red bucket) in cook's area. Logs for sanitizer bucket Parts Per Million (PPM) and sanitization levels were not completed.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 8 employees were screened for a history of abuse, neglect, exploitation, or misappropriation of resident property to prohibit abuse, neglect, and exploitation of resident property, as state and federal regulations require. -Facility did not screen Registered Nurse (RN) H for an out of state Background Information Disclosure (BID) when hired.

Inspectors wroteBased on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for each resident (R) to meet medical, nursing, and psychosocial needs identified for 2 of 12 sampled residents (R0 (R3 and R8). R3 and R8 did not have a sleep hygiene care plan developed when prescribed medication to promote sleep. This is evidenced by:Example 1R3 was admitted to the facility on [DATE]. R3's current diagnoses include in part, cerebral infarction, type 2 diabetes mellitus, anxiety, aphasia, hemiplegia right dominant side, narcolepsy, and atrial fibrillation. R3's physician orders documented an order on 03/01/25 to give melatonin 5 mg by mouth daily HS (bedtime) for insomnia. On 06/26/25, a sleep assessment was completed documenting R3 on average sleeps 7-8 hours with a goal of 8 hours and try to avoid excess fluid intake. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 12 residents (R) reviewed, R14. Facility staff did not follow R14's physician orders for administration of insulin. This is evidenced by: R14 was admitted to the facility on [DATE]. R14's current diagnoses include type 2 diabetes mellitus, vascular dementia, and adult failure to thrive. R14's cognition is moderately impaired and requires staff supervision when eating. Review of R14's physician medication orders documented in part. 03/05/24 Insulin Glargine 22 units daily in AM, FOR: type 2 diabetes mellitus.04/9/24 Insulin Lispro 8 unit twice a day at Breakfast and Midday (Lunch) HOLD if meal intake is less than 25%, FOR type 2 diabetes mellitus.04/9/24 Insulin Lispro 6 units daily at Supper. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R4) received care consistent with professional standards of practice to prevent the development of a new pressure injury and did not ensure the plan of care was consistently followed for R4, who is at risk for pressure injuries. R4 was at risk for PI development. R4 had an area of concern on right heel. The facility failed to provide adequate and consistent repositioning to off load R4's heels and buttock. This is evidenced by:Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 31, July 2025, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions and supervision when needed to prevent accidents which effected 1 of 4 residents (R2) reviewed for falls. -Certified Nurse Assistant (CNA) D transferred R2 from wheelchair to bed without gait belt in place during transfer process.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory treatments (R5). This is evidenced by:The facility procedure Using Small Volume Nebulizers, from book titled Clinical Nursing Skills and Techniques 11th edition, by [NAME] which states: Assessment6. Perform hand hygiene. Assess pulse, respirations, breath sounds, pulse oximetry, and peak flow meter (if ordered) before beginning treatment. Implementation12. Rinse nebulizer cup per agency policy. R5 was admitted to the facility on [DATE] and has diagnoses that include tetralogy of fallot, COPD, acute respiratory failure with hypoxia, macrocephaly, disturbances of salivary secretion, anxiety disorder and persistent mood affective disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not 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 diseases and infection. Licensed Practical Nurse (LPN) M observed administering medication for 2 consecutive hours with improper hand hygiene opportunities for 4 of 4 residents observed. (R11, R18, R19, R22). Staff did not wear appropriate PPE for cares with R5 and R1. Staff did not perform hand hygiene when needed during cares for R14.

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1). This is evidenced by: Facility's policy titled, Resident Safety Abuse Policy, revised date 02/2022, read in part: 8. Reporting Suspected Violations: a. the supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. [...]

Inspectors wroteBased on observation and staff interview, the facility did not ensure food was stored and served under sanitary conditions. This practice had the potential to affect 32 residents. Foods opened without a date. Dry storage items found on the floor. Temperature documentation missing for temping foods. Temperature/Chlorine documentation for dishwasher missing.

Inspectors wroteBased on observation, record review and interview, the facility did not implement a restorative program in attempt to improve or maintain residents' functional abilities for 5 of 7 residents (R21, R15, R12, R29 and R7) reviewed for limited Range of Motion (ROM).

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 3 of 8 staff reviewed.

Inspectors wroteBased on record review and interview, the facility did not conduct a comprehensive and accurate assessment for 1 of 13 residents (R) reviewed for Minimum Data Set (MDS) assessments. (R5)

Inspectors wroteBased on observation, interview and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper hand hygiene practices were followed during resident care and wound care observations. This occurred for 2 of 7 residents (R) 31 and R15.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R2) reviewed for falls had adequate supervision and assistance to prevent accidents. R2's care plan indicated the use of an alarm while in wheelchair. R2's alarm was not in the 'ON' position.

Inspectors wroteBased on observation, interview and record review, the facility did not have behavior monitoring for targeted behaviors, and non-pharmacological interventions for behaviors prior to the use of psychotropic medications. The facility did not have an appropriate indication for use for the psychotropic medication. This occurred for 2 of 3 residents (R) reviewed for unnecessary medications. (R1, R2) -R1 and R2 received anti-anxiety medications that did not include adequate indication for use of this medication. -The facility does not have a system for monitoring and documenting behaviors, and effectiveness of medications, or non-pharmacological interventions implemented prior to the use of psychotropic medication.

Inspectors wroteBased on record review and interview, the facility did not consult with the resident's physician, consistent with his or her authority, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 sampled residents (R2). The facility did not notify the physician or Power of Attorney (POA) promptly of R2's fall on 10/03/23 or consult with physician timely of increase in pain and change in ambulation status post fall. R2 was sent to the emergency room 4 days after the fall and was diagnosed with a fractured right hip. The delay in consulting with a physician prevented timely diagnosis of the fracture and caused ongoing pain with movement. This is evidenced by: Facility policy titled Incidents and Accidents dated 12/2013, revised 08/2021 states: Purpose: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 out of 3 sampled residents (R) R2 received assessment and appropriate medical care with a change in medical condition consistent with professional standards of practice for a licensed practical nurse (LPN) and a registered nurse (RN). R2 was not assessed for increased pain or change in ambulation ability after a fall on 10/03/23 to secure timely treatment for R2. On 10/07/23, four days after the fall, R2 was sent to the emergency room and was diagnosed with a fractured right hip. R2 experienced increased pain, especially with movement during the four days the fracture went undiagnosed. This is evidenced by: Facility policy titled Incidents and Accidents dated 12/2013, revised 08/2021 states: Purpose: [...]

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure sanitary conditions while dishwashing. This has the potential to affect 37 of 37 residents in the facility. Kitchen staff moved from dirty to clean areas while washing dishes, without a change of gloves or handwashing done in between the tasks. This is evidenced by: On 5/23/23 at approximately 1:20PM, Surveyor observed Dietary Aide (DA) E walk into the dishwashing area wearing gloves with a dirty tray. DA E set the dirty tray down in the dirty side of the kitchen, opened the dishwasher door and moved the clean tray of dishes down the line, then went back and put the dirty tray in the dishwasher and closed the door. DA E did this all without changing gloves or washing hands. DA E was not wearing an apron, nor was there one available observed in the dishwashing area. [...]