Willowbend Health and Rehabilitation, LLC

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #25) of 4 sampled residents reviewed for neglect received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure 2 staff members transferred Resident #25 using the appropriate lift based on Resident #25's needs and care plan which resulted in Resident #25 sustaining a dislocated right shoulder. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 12/18/2024 at approximately 8:45 AM. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately indicate hospice care and dialysis on Section O of the Minimum Data Set (MDS) for 1 (Resident #75) of 2 sampled residents for hospice and 1 (Resident #34) of 1 sampled resident for dialysis.

Inspectors wroteBased on observation, interviews, and record review it was determined that the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 3 (Residents #92, #104, and #107) of 30 sample mixed residents whose care plans were reviewed.

Inspectors wroteBased on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure over-the-counter medications, and a narcotic medication prescribed to Resident #71, stored in the medication carts were not expired for 2 of 2 medication carts sampled.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, sealed and dated; 2 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; kitchen storage area was maintained clean; and hot food items were maintained at temperature of 135 degrees or above for 2 of 2 meals observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 1 (Resident #6) of 1 sampled resident whose records were reviewed for the PASARR screening information.

Inspectors wroteBased on record review and interview, the facility failed to fully assess a resident experiencing respiratory distress in a timely manner, failed to follow physician's order during an acute incident which resulted in a change of condition, and failed to notify the physician of the change in condition in a timely manner for 1 (Resident #368) of 3 sampled residents reviewed for a change in condition. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Residents #21, #81) of 2 sampled Residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately document a Discharge Minimum Data Set assessment for 1 (Resident #117) sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to minimize the potential for further decline in Range of Motion (ROM) for 1 (Resident #20) of 1 sampled resident who had limited range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise a resident's care plan with the participation of the resident's representative for 1 (Resident #39) of 111 residents who received a care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #20) of 1 sampled resident who had limited range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed contact isolation precautions, including the consistent, appropriate use of personal protective equipment (PPE) and supplies while providing care to Covid positive residents, and to ensure adherence to handwashing/sanitizing between glove changes and administering medications to prevent the potential spread of infection to other residents who resided in the facility.

Inspectors wroteBased on interview and record review, that facility failed to accurately assess Resident #12 on the Annual Minimum Data Set, who was considered by the state designated authority as Pre-admission Screening and Resident Review level II.

Inspectors wroteBased on the observation, interview and record review, the facility failed to ensure fingernail and toenail care was provided for 1 (Resident #20) of 2 sampled residents who required assistance with nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received incontinence care in a timely manner for 1 (Resident #10) of 3 sample Residents. The failed practice had the potential for skin breakdown, infection, and/or irritation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #18) of 3 (Residents #18, #35 and #100) sampled residents who had a siderail for an enabler and 1 (Resident #53) of 3 (Residents #5, #33, and #53) sampled residents who had a Pressure Ulcer.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a splint, hand roll, and/or other positioning device was consistently utilized to prevent further decline in range of motion for 2 (Residents #12 and #17) of 6 (Residents #5, #12, #16, #17, #31 and #53) sampled residents who had contractures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure necessary care and services were provided for management of urinary catheters, as evidenced by failure to ensure a urinary catheter was secured by a leg strap; an urinary catheter bag was kept below the resident's bladder to prevent the potential for trauma and/or Urinary Tract Infection (UTI) for 1 (Resident #35) of 2 (Resident #35 and #33) sampled residents who required indwelling catheters; and failed to ensure incontinent care was performed in a timely manner for one resident (Resident #97) of 24 (Residents #5, #11, #12, #16, #17, #18, #31, #33, #40, #53, #54, #73, #80, #83, #92, #93, #95, #97, #100, #102, #104, #106, #108 and #115) sampled residents who were dependent on staff for incontinent care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure updraft masks were stored in a proper container when not in use to prevent the potential for cross contamination and/or infection for 2 (Residents #80 and #73) of 4 (Residents #33, #73, #80 and #92) sampled residents who had updraft treatments; failed to ensure oxygen was administered at the correct flow rate as order by the physician to prevent potential complications for 2 (Residents #80 and #73) of 8 (Residents #5, #16, #17, #33, #73, #80, #92 and #95) sampled residents; and failed to ensure oxygen was administered with a physicians order to prevent potential complications for 1 (Resident #95) of 8 (Residents #5, #16, #17, #33, #73, #80, #92 and #95) sampled residents who were receiving oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu for 1 of 2 meals observed. This failed practice had the ability to affect 4 (Residents #11, #44, #104 and #108) sampled residents who had physician's order for a regular diet and who resided on Station 100. This failed practice had the potential to affect 12 residents according to a list provided by the Administrator on 01/06/23 at 8:20 AM.