Willow Ridge of Nc

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop accurate care plans when the facility wrote care plans for cognitively impaired residents for activity they were unable to consent to and wrote goals and interventions that would not apply to the residents for 4 of 8 residents whose comprehensive care plans were reviewed (Resident #10, Resident #12, Resident #101, and Resident #104).

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to provide personal privacy to residents when staff did not knock before entering resident rooms. This deficient practice affected 2 of 6 residents reviewed for privacy (Resident #94 and Resident #31).

Inspectors wroteBased on record review, resident, staff interviews, and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental health diagnosis for 1 of 3 residents reviewed for PASRR (Resident #5).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 4 resident reviewed for foot care (Resident #94).

Inspectors wroteBased on record review and interviews with staff, Registered Dietician (RD), and the Nurse Practitioner, the facility failed to initiate a dietary supplement per the RD's recommendation when the resident experienced a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident #20).

Inspectors wroteBased on record review, observations, and interviews with residents, facility staff, the Medical Director, the Lieutenant from the Police Department, resident's family friend, and the resident's responsible person (RP), the facility failed to protect the resident's right to be free from resident-to-resident abuse for 2 of 3 residents reviewed for abuse (Resident #15 and Resident #57). On 4/12/24 while completing morning rounds, Nurse Aide (NA) #6 found Resident #366 in Resident #15's room, lying on top Resident #15 while she was asleep in her bed, with his brief pulled down and his penis exposed. Resident #15's brief appeared to be sideways, undone on the left side, but was in place between her legs. Resident #366 was placed on one-to-one supervision at this time due to wandering and sexualized behaviors. Both residents were severely cognitively impaired. [...]

Inspectors wroteBased on record review, Medical Director, Hospital Case Manager, Resident's Legal Guardian, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident remained in the hospital for over a month despite being cleared to return to the nursing home after 3 days. A reasonable person would expect once they were medically cleared from the hospital to be allowed back into their home and not being allowed back into their home could cause them to experience altered mental condition, fear, anxiety, and depressed mood. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #366).

Inspectors wroteBased on observation, record review, and interviews with residents and staff, the facility failed to ensure residents could access their light switch located behind the bed for 3 of the 3 residents reviewed for accommodation of needs (Resident #76, Resident #364, and Resident #54).

Inspectors wroteBased on record review, and Legal Guardian and staff interviews, the facility failed to communicate with the Resident's Legal Guardian and obtain authorization from the Legal Guardian prior to the Resident being transferred across state lines to a hospital in South Carolina (SC) for 1 of 3 residents reviewed for discharge (Resident #366).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide report an allegation of resident to resident abuse to the State Agency, law enforcement, and Adult Protective Services (APS) within the required timeframe and to ensure the report to all agencies included accurate information. The facility learned of an allegation of rape on 12/19/24, did not provide the information to law enforcement, and did not report the information to the State Agency until the investigation report was submitted on 12/26/24. This deficient practice affected 1 of 3 residents reviewed for abuse (Residents #57).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Residents #57).

Inspectors wroteBased on record review, legal guardian, and staff interviews, the facility failed to notify the Resident's legal guardian in writing of a transfer to the hospital in South Carolina for 1 of 3 residents reviewed for discharge (Resident #366).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the Care Area Assessment Summary (CAAS) of the Minimum Data Set (MDS) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 6 sampled residents reviewed for unnecessary medications (Residents #48 and Resident #82).

Inspectors wroteBased on record review, and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide recommendations for 1 of 7 residents reviewed for unnecessary medications (Residents #25).

Inspectors wroteBased on record review and interviews with residents, staff, and the Medical Director (MD), the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #25).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to secure an opened tube of topical paste for 1 of 1 Resident reviewed for medication storage. (Resident #99).

Inspectors wroteBased on observations and staff interviews the facility failed to post daily nurse staffing in a prominent location that was readily accessible to residents on 4 of 5 days during the survey (01/27/2025, 01/28/2025, 01/29/2025, and 01/30/2025).

Inspectors wroteBased on observations, record review and resident, family member (RP), staff and Medical Director (MD) interviews, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. Resident #1 flipped backwards in his wheelchair, hitting the van floor while being transported in the facility's transportation van when the transportation van drove over a speedbump located along the steep driveway leading to the facility. Resident #1 sustained a hematoma to the back of his head, a skin tear to his right hand and skin tear to his right wrist. This practice had the high likelihood of causing serious injury for 1 of 3 residents reviewed for accidents (Resident #1). The immediate jeopardy began on 12/21/23 when Resident #1 flipped backwards in his wheelchair hitting the transportation van floor. [...]

Inspectors wroteBased on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following recertification and complaint investigation surveys completed on 11/12/21 and 11/3/23. This failure was for one deficiency in the area of supervision to prevent accidents that was subsequently recited on the current complaint investigation and revisit survey of 01/16/24. The repeat deficiency during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.

Inspectors wroteBased on observation, record review, staff and physician assistant interviews, the facility failed to safely assist a resident without causing injury to 1 of 5 residents (Resident #86) reviewed for accidents. Resident #86 was left standing without assistance in her room and fell. Resident #86 sustained a laceration to the head and a right fractured hip.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to store medications according to manufacturer's guidelines on acceptable temperature range for 2 of 3 medication refrigerators (Unit A Station Medication Room), failed to date an opened Tuberculin Purified Protein Derivative (PPD) for 1 of 3 medication refrigerators (Unit A Station Medication Room) and failed to store unopened insulin in the medication refrigerator as specified by manufacturer's guidelines for 1 of 6 medication carts (Unit C Station Medication Cart #2) reviewed for medication storage.

Inspectors wroteBased on observations, resident interviews, staff interviews and record reviews the facility failed to provide dental services for a resident who desired dentures. This was evident for 1 of 2 residents reviewed for dental services (Resident #97).

Inspectors wroteBased on observations and staff interviews the facility failed to ensure staff wore hair coverings when working in food production areas for 1 of 1 meal production observations. This practice had the potential to affect food served to residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 10/28/22 and 11/12/21. This failure was for three deficiencies cited in the areas of Free of Accidents/Hazards, Labeling and Storing of Drugs and Biologicals, and Food Procurement and Storage which were subsequently recited on the current recertification and complaint investigation survey of 11/03/23. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observations, record review and resident and staff interviews, the facility allowed a resident that had been assessed as unable to self-administer medications to self-administer medications via a gastrostomy tube (G-tube). This occurred for 1 out of 1 resident reviewed for medication administration (Resident #227).

Inspectors wroteBased on resident, staff, responsible party, and family interviews, and record reviews the facility failed to notify the Responsible Party of a new wound (Resident #17) and the Power of Attorney (POA) or family of a fall and being sent out to the hospital for evaluation (Resident #95) for 2 of 2 sampled residents reviewed for notification of changes.

Inspectors wroteBased on observations, resident interviews, staff interviews and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of oral and dental status (Resident #97) for 1 of 2 sampled residents.