Willow Terrace

Inspectors wroteBased on review of clinical records, facility documents, and interviews with staff, it was determined the facility failed to ensure one of ten residents reviewed were free from verbal abuse. (Resident R1)Findings Include: Review of the facility policy titled Abuse Policy-Prevention and Management last revised September 2022 states verbal abuse is defined as, Verbal Abuse- Oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: [...]

Inspectors wroteBased on review of clinical records, facility documents, and interview with staff and residents, it was determined the facility failed to ensure Resident R1 was free from physical abuse. This failure resulted in actual harm to Resident R1 who was grabbed by a facility's employee by the collar, held in a choking position and placed (his/her) hand on the resident's face. The employee's hands had to be pried away from Resident R1's. A reasonable person would determine that a staff member holding a resident with a diagnosis of major depression and heart failure in a chocking hold caused actual harm, placing Resident R1 at risk for psychological trauma or one of five residents reviewed.

Inspectors wroteBased on review of clinical records, facility documents, and interview with staff and residents, it was determined that the facility failed to ensure to immediately protect a resident involved in a staff to resident abuse for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on review of facility documents, review of clinical record, review of facility policies, interview with staff and residents, it was determined that the facility failed to ensure that all alleged violations involving abuse is reported immediately, but not later than 2 hours after the allegation is made for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical record, review of facility documents and review of facility policy, it was determined that the facility failed to assess/evaluate a resident after an incident of physical abuse for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical record, facility policy, and staff interview it was determined that the facility failed to ensure that a resident was informed of and allowed to exercise their right to leave the facility Against Medical Advise (AMA) for one out of 5 residents reviewed. (Resident CL1). Findings Include:A review of the facility policy titled Discharge Against Medical Advice (AMA), last revised 6/2025, stated: A Discharge Against Medical Advice form must be completed when a cognitively intact resident/patient or the legally responsible party for a non-cognitively intact resident/patient insists on leaving the facility Against Medical Advice (AMA). The attending physician, CEO, and Director of Nursing must be notified immediately following each AMA.Review of Resident CL1's nursing notes indicated that the resident was admitted to the facility on [DATE], at approximately 6:30 p.m. [...]

Inspectors wroteBased on clinical record reviews, interviews with staff, reviews of hospital records and policies and procedures, it was determined that the facility failed to provide the behavioral health care and services to meet the needs of one of sixteen residents reviewed to ensure that each resident attained or maintained the highest practicable physical, mental and psychosocial well-being. (Resident CL1)

Inspectors wroteBased on the review of clinical records, job descriptions, facility policy, facility documentation, and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not investigate alleged violations or incidents related to a resident not being informed of and allowed to exercise their right to leave the facility Against Medical Advice (AMA) for one out of five residents reviewed (Resident CL1). Findings Include:Review of the facility policy titled Incident Reporting and Investigation of Accident Hazards, and Supervision, Assistive Devices, last revised October 2024, revealed the following:It is the policy of the Facility to monitor and evaluate any adverse occurrence that is not consistent with the routine operation of the Facility or the care of a resident(s). [...]

Inspectors wroteBased on review of facility policy, staff interviews and review of clinical records, it was determined that the facility failed to ensure that weights, nutritional assessments, notifications to the physician of a significant weight loss were completed in a timely manner, and that nutritional interventions were implemented for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. Resident R1 was unable to be located for over six hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. [...]

Inspectors wroteBased on the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility. This failure resulted in an Immediate Jeopardy situation for Resident R1 who was missing from the facility overnight for approximately six hours. (Resident R1) Findings Include: [...]

Inspectors wroteBased on observations, review of facility records, interviews with resident and staff, it was determined that the facility failed to ensure comfortable and safe temperature levels. Facilities failed to maintain a temperature range of 71 to 81°F for four of four resident rooms. (301, 302, 311, 328) Findings Include: Interview with Resident R169 on January 28, 2025, at 11:00 a.m. with Maintenance Director, Employee E9 stated the room temperature was too high, and she was suffocating in the room. She stated she had COPD and would like the room temperature at 72-degree Fahrenheit. Interview with Resident R134 on January 28, 2025, at 11:35 a.m. it was too hot for her, and she needed fan to make her comfortable. Resident stated it's been a month since the facility had the temperature issue. Interview with Resident R151 on January 28, 2025, at 11:34 a.m. stated it was very hot in the facility. [...]

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for three of four residents reviewed for psychotropic medications (Residents R142, R139 and R158).

Inspectors wroteBased on the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a resident/resident representative grievance was promptly documented and resolved for one of 32 resident records reviewed. (Resident R110) Findings Include: Review of facility policy Grievance/Concern Form; Grievance/Concern Log revised October 28, 2021 revealed Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form or completing a review on the customer service kiosk when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. [...]

Inspectors wroteBased on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged sexual abuse to the State Agency and the Administrator as required for one of 32 residents reviewed (Resident R110).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that psychotropic medication changes met professional standards of practice for one of four residents reviewed for psychotropic medications (Resident R158).

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R151).

Inspectors wroteBased on observations of care and services, clinical record review, interviews with staff and residents and reviews of facility policies, it was determined that facility failed to ensure that each resident received proper treatment and assistive devices to maintain vision for one of two residents reviewed for communication needs. (Resident R138)

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R271).

Inspectors wroteBased on review of clinical records, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed conduct smoking assessment to ensure the safety of a resident who smokes for one of 32 residents reviewed. (Resident R14)

Inspectors wroteBased on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to maintain appropriate nutritional parameters for one of four residents reviewed. (Resident 65).

Inspectors wroteBased on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residents reviewed on renal dialysis (Resident R47)

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 32 residents reviewed (Resident R65).

Inspectors wroteBased on observations, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that agency licensed nurses had the specific competencies and skill sets necessary to care for residents' needs related to medication administration practices and infection control practices, for three of three agency staff reviewed (Employees E7, E8, and E10).

Inspectors wroteBased on clinical record reviews, interviews with staff, reviews of policies and procedures and the Department of Human Services assessments, it was determined that the facility failed to provide the necessary behavioral health care and services to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan for one of four residents reviewed with mental illness (Residents R17).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one of four medication carts reviewed (fourth floor south medication cart), and failed to ensure that medications were readily available for administration for three of 32 residents reviewed (Residents R132, R55, and R142).

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for one of three residents observed during medication administration (Resident R132).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that insulin pens and vials were labeled in accordance with currently accepted professional principles for one of four medication carts reviewed (fourth floor north medication cart).

Inspectors wroteBased on the review of facility documents and resident clinical record and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents reviewed (Resident R147 and Resident R151). Findings Include: Review of Resident R147's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 6, 2024, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of non-traumatic brain dysfunction and cognitive communication deficit. [...]

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain enhanced barrier precautions during wound care for one of one observations of wound care performed (Resident R271).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to obtain and follow physician orders related to medications, wound care and dietary recommendations for three of five residents reviewed (Residents R1, R2 and R3).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were treated in a dignified manner for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from abuse, which resulted in actual harm to Resident R2 who was pushed by a nursing staff, fell to the floor and sustained an acute fracture of the distal radial metaphysis for one of eight residents reviewed. (Resident R2)

Inspectors wroteBased on review of facility policy, review of facility records, observations, and interviews with residents and staff it was determined that the facility failed to provide a safe, homelike environment for one of four resident units observed. (Unit Three) Findings Include: Review of facility policy titled, Temperature Extremes dated September 2017 states, The policy of [NAME] Terrace is to provide comfortable and safe temperature levels. The temperature throughout this facility shall be maintained at between 71 degrees and 81 degrees Fahrenheit. Any temperatures outside of this range requires specific intervention(s) to avoid potential negative impact on the residents' well-being. Should the A/C or heating system fail, specific monitoring and safety measures should be activated. Additional responses listed as, 1. Maintain a log of temperature monitoring. [...]

Inspectors wroteBased on review of clinical record and interview with staff, it was determined that the facility failed to inform residents of tests results and the facility failed to follow-up on the result of test results resulting in a delay in providing resident of the test results for one of seven residents reviewed (Resident R1)

Inspectors wroteBased on observation, and review of resident clinical records, it was determined that the facility failed to ensure proper accommodation of needs for one of 32 residents reviewed regarding appropriate bed size and mattress (Resident R17).

Inspectors wroteBased on observations, clinical record reviews, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for three of five residents reviewed (Residents R96).

Inspectors wroteBased on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to ensure a resident who required respiratory care received the necessary care and services in accordance with professional standards of practice, and resident's plan of care for one of 32 resident records reviewed (Resident R96)

Inspectors wroteBased on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure each resident received the necessary behavioral health services in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 32 resident records reviewed (Resident 18 and R61).

Inspectors wroteBased on review of clinical records and interview with staff and review of facility policy, it was determined that the facility failed to provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident by failing to assist in community placement options until completion for one of 32 resident records reviewed (Resident R61).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for two of 32 residents reviewed (Resident R17 and R96).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable, attractive, and served at the proper temperature for one of five nursing units observed (third floor nursing unit)

Inspectors wroteBased on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of four residents reviewed for nutrition (Resident R149). Findings Include: Review of facility diet guide sheet revealed Tuesday lunch offerings on March 25, 2024, was Herb Rubbed Pork, Parley New Potatoes, Braised Cabbage, and Chilled Peas. Per the diet guide sheet, a resident on a mechanically soft diet (consisting of food that have been bended, mashed, pureed, or chopped, making them soft and easy to eat without biting or chewing), should receive ground herb rubbed pork, mashed potatoes, and pureed braised cabbage. Review of Resident R149's physician orders revealed the resident was ordered a Mechanically Soft Textured diet dated January 25, 2024. [...]

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on interviews with residents and staff and review of clinical records, it was determined that the facility failed to ensure timely provision of professional services furnished by outside providers, for one of 32 residents reviewed (Residents R17).

Inspectors wroteBased on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: Review of facility policy titled, Dish Machine Usage Policy, revised November 15, 2023, revealed that dishwasher staff will monitor and record dish machine temperatures to assure compliance for wash and rinse cycles . FSD (food service director) or Designee will monitor temperature log and PPM readings prior to each usage for compliance. An initial tour of the main kitchen was conducted on March 25, 2024, at approximately 10:19 a.m. with the Food Service Director (FSD), Employee E3. Observations of the dish room revealed Dietary Aide, Employee E4, was utilizing the dish machine. [...]

Inspectors wroteBased on clinical record review, observation of medication administration and staff interview, it was determined that the faciltiy failed to ensure that medications were administered timely for one of nine residents reviewed. (Resident R1)

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five residents (Resident R1).

Inspectors wroteBased on observations, review of facility policy and interviews with staff and residents it was determined the facility failed to provide food that was palatable, attractive, and served at appetizing temperatures for one of four units reviewed. (Unit four) Findings Include: Review of the facility policy titled, Recording Food Temperatures Policy last revised 8/16/18 states, Purpose: To ensure the quality and safety of food are met by providing and maintaining proper food temperatures during meal service. 6. Hot food will be maintained at 135 degrees or higher. The facility failed to ensure all food was maintained at 135 degrees Fahrenheit or higher. Interview with Resident R2 on September 28, 2023 at stated that the food comes cold, they let it sit twenty to thirty minutes. The resident stated he eats all his meals in his room and the meals are cold. [...]

Inspectors wroteBased on observations, review of facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities for two of 42 residents reviewed (Residents R268, R76)

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to provide appropriate serving equipment to dietary staff during dining services to ensure that menu portions were properly served, on one of four nursing units observed (Fourth Floor nursing unit).

Inspectors wroteBased on review of facility polices, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide a resident the right to participate in the care planning process, of 42 residents reviewed (Resident R63).

Inspectors wroteBased on a resident council meeting, resident interview, review of facility policy and procedures and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents' locations on the nursing units for 4 of 4 nursing units observed. (Floor 3, 4, 5, 6)

Inspectors wroteBased on clinical record review, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of three residents reviewed (Residents R58 and R268).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two of eight residents reviewed (Resident R54 and R3)

Inspectors wroteBased on observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident received appropriate treatment and services for contracture management as prescribed for one of one residents reviewed for contracture management (R62).

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for two of 33 residents with weight loss reviewed (Resident R21, R89).

Inspectors wroteBased on observations, staff and resident interview, and clinical record review, it was determined that the facility did not ensure that a resident who was incontinent of bowel received care in a timely manner for one out of eight residents reviewed (Resident R4)

Inspectors wroteBased on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not ensure that adequate activities were provided, that medications utilized for the management of dementia were appropriately prescribed, and that an individualized, person-centered care plan was developed and implemented to address a resident's dementia care needs for one of 33 records reviewed (R102).

Inspectors wroteBased on observation, review of facility policies and interviews with staff, it was determined that the facility failed to provide appropriately textured foods to meet the needs of residents on a mechanically altered diet, on two of four nursing units observed (Fourth and Fifth Floor nursing units).

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined that the failed to maintain legible clinical records for 2 of 42 residents reviewed (Residents R21 and R268).