Willowbrooke Ct Skilled Care Ctr Westminster Vlg

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to store, prepare, and serve food under sanitary conditions for 38 of 38 residents who received food prepared in the kitchen. Observations on 4/6/21 in the kitchen revealed uncovered, unrefrigerated, and unlabeled food, no dates on prepared food, storage containers containing debris and unclean workstations.

Inspectors wroteBased on observations, interviews, and review of a facility policy titled PERSONAL APPEARANCE STANDARDS, the facility failed to ensure: 1) opened and undated foods were not observed in the freezer; 2) the ice machine was not found with a black residue inside the ice storage compartment; and 3) hair was not uncovered on staff while working in the kitchen. This had the potential to affect all forty-two residents receiving meals from the kitchen. Findings Include: 1) On 2/12/2019 at 7:56 AM, during the tour of the kitchen, a brown paper bag of hashbrowns was observed opened and exposed with no date. A brown paper bag of tater tots was also observed open and exposed to air, without a date. On 2/14/2019 at 1:35 PM, Employee Identifier (EI) 3, the Director of Culinary Services, was interviewed. [...]

Inspectors wroteBased on observations, interviews and record reviews, including the facility's policy titled, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, and the Food and Drug Administration Food Code, the facility failed to ensure: 1) a container of chopped fruits, a tray of hamburger patties, and a container of green beans had an expiration date on them; 2) a tray of fruit cups and bowls of bread pudding were covered and dated; and 3) a pan of brownies in the cooler was covered. This affected 40 of 40 residents who receive a meal from the kitchen. Findings Include: A review of the Food and Drug Administration Food Code 2013, Chapter 3 Food Storage page 76, revealed the following: .3-305-11 Food Storage : (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the FOOD: .(2) Where it is not exposed to splash, dust, or other contamination; [...]

Inspectors wroteBased on interviews and a review of a facility policy titled, Abuse, Neglect . the facility failed to ensure the Abuse Policy indicated the reporting time of alleged abuse within two hours of being reported by staff to administration. This affected RI #4, #5, and #15, three of three residents named in allegations of abuse reviewed and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: [...]

Inspectors wroteBased on interviews, review of abuse allegation files, and the review of a facility policy titled, Abuse, Neglect ., the facility failed to ensure three allegations of abuse were reported to the State Agency within two hours of being reported by staff to the administration. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents named in allegations of abuse the facility reported to the State Agency and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: [...]

Inspectors wroteBased on interviews, the Abuse Policy, and Alleged Abuse Reports submitted to the State Agency from 11/17 to 02/18, the facility failed to ensure the Administrator, who was responsible for the overall management of the facility, and the Director of Nursing, who was responsible for the overall management of the Nursing Department, ensured the facility reported alleged abuse of three residents within the two hour required time period. This affected RI (Resident Identifier) #4, #5, and RI #15, three of three residents named in alleged abuse incidents from 11/17 through 2/18, and had the potential to affect all residents involved in abuse allegations residing at the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION with a revision date of 11/17, revealed: POLICY: [...]

Inspectors wroteBased on record review of the policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, and interviews, the facility failed to ensure the Governing Body maintained a process that ensured the abuse policy contained the correct time frame for reporting alleged abuse. This was evidenced by the Abuse Policy not indicating the required two hour reporting period for all alleged abuse. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents with facility reported alleged abuse allegations and had the potential to affect all residents involved in abuse allegations who reside in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: [...]

Inspectors wroteBased on interviews and a review of the facility policy and procedure titled, Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program, the facility failed to ensure the QAPI committee reviewed and identified the required regulatory change for reporting allegations of abuse within two hours to the State Agency. This affected three of three reported allegations of abuse submitted to the Alabama Department of Public Health and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of a facility policy titled,Quality Assurance, Performance Improvement and Compliance Manual, revealed: Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program Purpose: The purpose of . [...]

Inspectors wroteBased on interviews and a review of POTTER/[NAME], FUNDAMENTALS OF NURSING the facility failed to ensure the documents of an abuse investigation were complete and correct as evidenced by forms with no dates, times, and incorrect dates. This was revealed in one of three allegations of abuse reported to the State Agency and affected RI (Resident Identifier) #4, one of three reports reviewed for alleged abuse. Findings Include: A review of POTTER/[NAME], FUNDAMENTALS OF NURSING, 9TH EDITION, Chapter twenty-six, Documentation, page 361, revealed: .Guidelines for Quality Documentation, . High quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete . Accurate . [...]

Inspectors wroteBased on observation, interview, and review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, the facility failed to ensure staff posting was not completed on all shifts prior to the shift worked. This was observed on two of four survey days and had the potential to affect all residents in the facility. Findings Include: A review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, with a revision date of 7/16, revealed: POLICY: To strive to post staffing information as scheduled for a twenty four (24) hour period. PROCEDURE: .2. The information should be posted at the beginning of each shift, with any needed changes made as soon as possible. On 2/27/18 at 12:50 P.M., the DAILY NURSE STAFFING FORM was observed in a plastic stand at the nurses station with the total hours of all three shifts filled out completely. [...]