Willow Wood at Woldenberg Village

Inspectors wroteBased on observations and interviews, the facility failed to ensure a resident shower room and resident shower equipment were maintained in a sanitary manner for 3 (Shower Room X, Shower Room Y, Shower Room Z) of 6 shower rooms observed for environment requirements.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's medication was administered as ordered by a physician for 1 (Resident #8) of 25 sampled residents investigated for compliance with physician orders.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident with diabetes (a chronic condition where your blood sugar is too high) and peripheral vascular disease (a slow circulation disorder where the blood vessels outside your heart and brain become narrow or blocked) received needed foot care for 1 (Resident #9) of 2 sampled residents investigated for foot care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store raw chicken in a sanitary manner for 1 (Cooler a) of 2 walk-in coolers observed in the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide surveyor staff during the survey with the requested complete Quality Assurance and Performance Improvement (QAPI) documentation, including the facility's identified quality concerns necessary to evaluate the effectiveness of the facility's QAPI program as evidenced by the removal of identified quality concerns from the document produced to surveyors.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. ensure the facility completed evaluations after a resident sustained a fall per policy (Resident #17 and Resident #75); 2. ensure a resident's care plan was revised with new individualized interventions after a resident sustained a fall (Resident #17 and Resident #75); 3. ensure oxygen tanks were secured and not free standing (Resident #102). This deficient practice was identified for 3 (Resident #17, Resident #75, Resident #102) of 5 (Resident #6, Resident #17, Resident #31, Resident #75, Resident #102) sampled residents reviewed for accident hazards.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #6) of 1 (Resident #6) sampled resident investigated for the self-administration of medications.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with a new diagnosis of schizophrenia was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a pressure reducing mattress was inflated for a resident who was identified as at risk for skin breakdown for 1 (Resident #75) of 3 (Resident #51, Resident #75, Resident #80) sampled residents investigated Per the Surveyor Workload Report by Investigation they were investigated for Pressure Ulcer/ Injury.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into the stomach) as ordered for 1 (Resident #46) of 1 (Resident #46) sampled resident investigated for enteral nutrition requirements.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to serve food in a sanitary manner for 1 (Resident #51) of 10 (Resident #10, Resident #26, Resident #41, Resident #50, Resident #51, Resident #54, Resident #74, Resident #83, Resident #88, Resident #92) sampled residents investigated for dining observation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was not required to supply a personal sitter (a caregiver who provides bedside assistance and supervision for safety) as a condition of continued stay for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for resident rights.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify a resident's representative and the State's Long-Term Care Ombudsman in writing of a resident transfer for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for transfer and discharge requirements.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the daily nurse staffing information was posted daily in a prominent place readily accessible as required.

Inspectors wroteBased on observations and interviews, the facility failed to ensure insulin (a medication used to lower blood sugar) was discarded within 28 days of the date it was opened on 1 (Cart a) of 3 (Cart a, Cart b, and Cart c) medication carts observed for medication storage.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to: 1. Ensure raw chicken was thawed in a sanitary manner; 2. Ensure the walk in cooler was kept clean and sanitary; 3. Ensure the walk in freezer was free of excessive ice accumulation; and, 4. Ensure water temperature and the concentration level of the sanitizing solution in the facility's 3 compartment sink and dishwasher were monitored and at the level required per the manufacture's guidelines.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's medication was available to be administered for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #1) of 3 (Resident #1 Resident #2, and Resident #3) sampled residents investigated for abuse. The facility's noncompliance resulted in actual harm on 11/03/2023 when Resident #2 bit Resident #1 on the right arm area above the wrist resulting in the resident screaming in pain with a visible bite and teeth marks on the skin requiring first aid treatment.