Willow Springs Rehabilitation and Healthcare Cente

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, and dishes were stacked dry. These failures had the potential to affect 153 residents who consumed food prepared by the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) when entering a room with a resident on transmission-based precautions, droplet precautions, and while providing direct care to a resident on enhanced barrier precautions (EBP) for two of five residents (Resident (R)40 and R89) reviewed for infection prevention and control out of a total sample of 49 residents. This failure placed staff and residents at risk of infection from cross-contamination.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to promote a dignified dining experience by standing to feed two of 15 residents (Resident (R)42 and R101) reviewed for dignity while dining on the Memory Care Unit. This failure had the potential to negatively impact the quality of life for the affected residents.

Inspectors wroteBased on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 calendar days after one of one resident (Resident (R) 36 elected hospice benefits out of a sample of 33 residents. This failure could potentially place the resident(s) at risk for unmet care needs being addressed, coordination of hospice care, and care planning of the resident.

Inspectors wroteBased on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 33 sampled residents (Residents (R) 9 and R36) receiving hospice services. Failure to ensure the accuracy of the MDS for residents receiving hospice services could lead to inaccurate assessment, place the residents at risk for unmet care needs being addressed, and care planning of the residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure two of 33 sampled residents (Resident(R)7 and R174) received a baseline care plan within 48 hours of admission into the facility. This deficient practice had the potential to allow residents not to receive the instructions for a person-centered care plan after admission.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of one resident (R36) receiving hospice services out of a total of 33 sampled residents. This deficient practice placed the resident at risk for unmet resident care needs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure feeding tube placement was verified prior to administering a nutrition supplement for one of two residents (Resident (R) 89) reviewed with feeding tubes out of a total sample of 33. This failure had the potential to place residents at risk of aspiration and hospitalization.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen (O2) concentrators had filters or were free of dust for one of one sampled resident (Resident (R)66) out of a sample size of 33. This failure had the potential for residents to have an increased chance of unnecessary respiratory treatments and/or infection.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to pharmacy implement processes for receiving controlled substances (CS) for two (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) of three medication carts observed for medication storage and labeling. This failure had the potential to create a risk of drug diversion, theft, improper handling of returns, all impacting patient safety and compliance.

Inspectors wroteBased on observation, policy review, and interviews, the facility failed to remove expired medications stored in two of three medication carts (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) observed for medication storage and labeling. This failure had the potential for reduced effectiveness or ineffective treatment of medical issues and was at risk for bacterial growth.

Inspectors wroteComplaint # 180991 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 12/09/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 4 residents (Resident #1). The facility also failed to follow its policy titled Administering Medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteC/O # NJ163363 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to: a) assess a resident (Resident #534) in a timely manner by a Registered Nurse (RN) who had an unwitnessed fall which resulted in the resident experiencing pain and a right hip fracture. Resident #534 fell on 4/16/23 at approximately 6:00 PM, and was not assessed until the next day at approximately 10:15 AM (over 12 hours) by the Medical Doctor. This deficient practice was identified for 1 of 4 residents reviewed for falls; and b) failed to ensure that there was a physician order for the use and monitoring of a safety device (Wander Bracelet) used to prevent residents from elopement (leaving a specified area without permission or supervision) in place. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide the necessary care and maintenance of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident #6). This deficient practice was evidenced by the following: During initial tour on 07/08/2024 at 8:08AM, the surveyor observed Resident # 6 oxygen tubing not labeled, and the bag that held the tubing when not in use was also not dated. On 07/09/2024 at 09:11 AM during an observation of Resident #6, the Oxygen tubing was not labeled or dated. On 07/10/24 at 10:12 AM during an observation of Resident #6, the oxygen tubing and bag were not labeled or dated. According to the admission Record, Resident #6 was admitted to the facility with diagnoses including but not limited to, Respiratory Failure with Hypoxia and Asthma. [...]

Inspectors wroteResident #122 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure specific target behaviors were monitored prior to the administration of an anti-psychotic medication for a resident who received an anti-psychotic medication (Seroquel) since May of 2024. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #122), and was evidenced by the following: On 7/8/2024 at 9:45 AM, the surveyor observed Resident #122 in the dayroom seated in a wheelchair. The resident stated they had woken up early and had just come from therapy and stated his/her mood was fine. The surveyor reviewed the medical record for Resident #122. [...]

Inspectors wroteComplaint # NJ00168248, NJ00168274 Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the Facility Assessment revealed under the Staffing Guidelines that the facility created a staffing pattern to ensure their residents needs are met on a consistent basis. The assessment went on to indicate that Our facility staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of New Jersey's regulatory requirements for ratios of direct care staff members to residents into our staffing baseline. [...]

Inspectors wroteComplaint # NJ 160656 Based on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure medications, treatments, and Enteral feedings were administered within the required time frame consistent with professional standards and facility policy. This deficient practice was identified for 1 of 7 residents (Resident # 234) reviewed for medication, treatment, and Enteral feedings administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteComplaint #: NJ156378, NJ157304, NJ157715, NJ158101, NJ159337, NJ159347, NJ159775, NJ160752 Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure the personal privacy of a resident's body during an incontinence care check. This deficient practice was identified for 1 of 1 residents reviewed for privacy (Resident #14) and was evidenced by the following. According to the admission Record (AR), Resident #14 was admitted to the facility with diagnoses which included but were not limited to, Diabetes (high blood sugar levels), Depression (a mood disorder that causes persistent sadness and loss of interest), and Unspecified Epilepsy (a neurological disorder that causes seizures). 1.) On 07/03/2024 at 9:59 A.M., the Surveyor observed Resident #14 in bed with head of bed elevated at 45 degrees. [...]

Inspectors wroteComplaint#: NJ159347 Based on observations and interviews, it was determined the facility failed to maintain a clean and homelike environment for 1 of 3 nursing units (Applewood Unit). The deficient practice was evidenced by the following: The surveyor toured the Applewood Unit on 07/03/2024 and observed the following: 1.) On 07/03/2024 at 9:05 A.M., upon entering the unit, the Surveyor noted a strong urine odor on the unit. The Surveyor observed the Housekeeper on the unit during the tour. 2.) On 07/03/2024 at 1:55 P.M., the Surveyor returned to the unit and as soon as the doors to the unit were opened, the Surveyor noted a strong pungent odor. The Surveyor noted a strong odor of feces while on unit. The Surveyor did not observe any dirty linens on the cart during the tour. Incontinence care was not being provided during that time. [...]

Inspectors wroteComplaint #: NJ159337 Based on interviews and records review on 07/02/2024, 07/03/2024 and 07/05/2024, it was determined that the facility failed to ensure a resident (Resident #19) was free from a medication error for 1 resident of 3 residents (Resident #19) reviewed for medication administration and follow their policy titled Medication Administration. Resident #19 received medication in error that was not prescribed to be administered to the resident. This deficient practice was evidenced by the following. [...]

Inspectors wroteComplaint #: NJ00166428 Based on interviews, medical record review, and review of other pertinent facility documents on 11/02/23 and 11/03/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. The deficient practice was identified for Resident #1, 1 of 4 residents reviewed for documentation and was evidenced by the following: The surveyor reviewed the closed record for Resident #1: According to the admission Record, Resident #1 was admitted on [DATE], with medical diagnoses that included but were not limited to fracture of unspecified part of neck of right femur (thigh bone), dementia, moderate with other behavioral disturbance, aphasia (language disorder of expression and comprehension), and muscle wasting and atrophy (decrease in size). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 4 of 4 medication carts on 2 of 2 (Cedar and Birch) nursing units reviewed for medication storage and was evidenced by the following: On 12/9/22 at 10:17 AM, while observing medication administration, the surveyor observed Licensed Practical Nurse (LPN #1) place a pre-filled insulin pen (injectable medication used to treat diabetes and lower blood sugar) with the needle still attached on Resident #70's tray table after administering the injection. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for two (2) of 29 residents reviewed Residents #114 and #112. This deficient practice was evidenced by the following: The surveyor reviewed the admission Record for Resident #114 which reflected that the resident was admitted with diagnoses that included schizoaffective disorder and essential hypertension. The surveyor reviewed the smoking safety evaluation dated 10/13/2022, which indicated that Resident #114 currently smokes. The surveyor reviewed Resident #114's admission MDS dated [DATE]. The section for current tobacco use was coded as zero (0) indicating that Resident #114 does not currently use tobacco. [...]

Inspectors wroteBased on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 12/6/22 from 10:15 AM -11:13 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The FSD wore a hair net on the top of his head with the sides and back of his hair exposed. The FSD acknowledged his hairnet and stated hairnets were required to be worn in the kitchen. [...]

Inspectors wroteb.) On 12/06/22 at 11:32 AM, the surveyor observed Resident #23 in their room resting with their eyes closed in bed on a pressure reducing, fully inflated air mattress (a mattress used to reduce the risk of pressure ulcers also known as bed sores). The resident had a sign on their room door indicating Enhanced Barrier Precautions and instructing the requirement to perform hand hygiene prior to entering and exiting the room and the use of PPE including gloves and gown when performing personal care for the resident or in contact with the resident. The surveyor reviewed the medical record for Resident #23. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for 1 of 2 unvaccinated staff on Cedar Unit and was evidenced by the following: On 12/6/22, during entrance conference, the facility was asked to provide a list of the COVID-19 staff vaccination status for all of their staff, which was provided by the Licensed Nursing Home Administrator (LNHA) on 12/7/22. On 12/12/22, the surveyor reviewed the list which revealed five staff members that were granted exemption from the COVID-19 vaccination. [...]