Willowcrest Health Services

Inspectors wroteBased upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the first quarter of 2025 (October 1- December 31), was accurate. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 67 residents.

Inspectors wroteBased on Observation, Interview and Record Review, the facility could not provide adequate proof of implementing an effective water management plan. This deficient practice had the ability to affect 67 of 67 residents residing at the facility at the time of this recertification survey. *The facility could not provide documentation of weekly temperature testing or weekly flushing logs for the vacant south unit (rooms 101-123).

Inspectors wroteBased on record review and interview, the facility did not ensure a Resident (R38) received the recommended dose reduction of a prescribed anti-anxiety medication. This was determined for 1 (R38) of 5 Residents reviewed. *On 5/8/25, Psychiatric NP (NP)-E recommended to discontinue R38's Lorazepam after a gradual dose reduction (GDR). The order to discontinue R38's Lorazepam was not completed following the recommendation on 5/8/25. Findings Include: The facility's Medication Monitoring, Medication Management, Section 8.4 last reviewed 01/24 documents: Policy .Based on a comprehensive assessment of a Resident, the facility must insure: -Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R27 & R55) of 2 residents were notified of the reason for transfer/discharge in writing and the rate to reserve the residents bed was not documented in the Wisconsin Bed Hold and Notice of Transfer.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R1) of 1 resident reviewed for bowel & bladder and who is incontinent of bowel receives appropriate treatment and services to monitor bowel movements. * R1 did not have a documented bowel movement from 2/1/25 through 2/9/25 and no bowel interventions were provided. On 2/10/25 R1 was diagnosed with a possible small bowel ileus.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R1) of 6 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R1 was assessed to have limited range of motion on one side for R1's upper extremities and both sides for lower extremities. There is no care plan for range of motion to prevent further decrease and range of motion was not observed during cares.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R20) of 1 resident with an indwelling catheter receives appropriate treatment & services. * Multiple observations were made of R20's indwelling catheter bag not covered and on the floor with no barrier.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R1) of 1 residents observed with tube feeding medication received the appropriate treatment and services to prevent complications. R1 did not have tube flushed prior to medication administration.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R55) of 1 residents receiving oxygen therapy. R55's oxygen was observed during the survey to be set at 4L (liter)/minute. R55's physician orders is for 3L/minute.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R22) of 1 resident reviewed for post traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional stands of practice and accounting or resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R1. R22 has a diagnoses of PTSD. R22's PTSD care plan is not person centered and does not include what R22's PTSD is related to, triggers for R22 and the interventions are not person centered.

Inspectors wroteBased on interview and record review, the facility did not ensure medications were accurately administered and controlled drugs were reconciled for 1 (R174) of 1 residents reviewed for medication error. R174 had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for pain. On 5/24/2025 at 10:53 PM and on 5/25/2025 at 5:42 AM, Licensed Practical Nurse (LPN)-C administered Zolpidem (Ambien) 5 mg (a hypnotic) instead of the ordered hydrocodone-acetaminophen 5-325 mg. The medication error was not identified at the change of shift from night shift to day shift on 5/25/2025 when the narcotic medications were to be reconciled with the narcotic count sheets.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R22) of 5 residents medication was adequately monitored. R22's physician order for Metoprolol Tartrate 100 mg (milligrams) twice daily includes instructions to hold the medication if R22's systolic blood pressure is less than 120. R22's blood pressure is not being taken to ensure R22's systolic blood pressure is above 120 prior to administering this medication.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of significant medication errors for 1 (R174) of 1 resident reviewed with a medication error. R174 had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for pain and Zolpidem (Ambien) 5 mg daily at bedtime for insomnia. On 5/24/2025, R174 received the scheduled dose of Ambien. On 5/24/2025 at 10:53 PM and on 5/25/2025 at 5:42 AM, Licensed Practical Nurse (LPN)-C administered Ambien 5 mg (a hypnotic) instead of the ordered hydrocodone-acetaminophen 5-325 mg. R174 received three doses of Ambien within 10 hours and R174 was sent to the hospital for altered mental status and complaints of intractable pain.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (R1) of 3 residents reviewed. The facility did not notify the physician of R1's low blood pressures as ordered.

Inspectors wroteBased on record review and interview, the facility did not maintain accurate nurse data information. This has the potential to effect all 79 residents currently residing in the facility. * The facility Nurse Staff Posting form does not document actual staff hours, and updates with each shift, and maintained for 18 months.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R127) of 1 Residents who did not have fully signed DNR (do not resuscitate) documents was provided with CPR (Cardiopulmonary Resuscitation). R127 returned from the hospital on 4/6/23. Upon return there is a verbal consent obtained on 4/6/23 from the POA (power of attorney)/daughter on the (CPR) Cardiopulmonary resuscitation consent form & Emergency Care Do Not Resuscitate Order (DNR). Facility staff did not follow up on having R127's POA/daughter sign these forms and the physician did not sign the Emergency Care Do Not Resuscitate Order (DNR). The Facility therefore did not have a valid DNR order. On 4/10/23 R127 experienced a choking episode, became unresponsive was not breathing & pulseless. Facility staff did not administer CPR as they thought R127 was a DNR. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 3 (R127, R63, & R45) of 8 Residents. R127 was readmitted to the facility on [DATE]. The hospital discharge summary for a discharge date of 4/6/23, under discharge recommendations documents 5. Diet: Diabetic (carb controlled) diet, low sodium; add protein supplements with meals (sugar free gelatin and low carb Glucerna). Per Speech Therapy: 1) Cont (continue) general solids, thin liquids; constant supervision/assist for all intake. 2) Meds (medication) whole in puree or with sips of liquid (minimum of 3 oz (ounce) liquid wash following same). 3) Small bites/sips, alternate solids/liquids consistently, slow pacing, stop intake if coughing increased, reflux precautions. [...]

Inspectors wroteBased on observation and interview the facility did not follow professional standards for food service safety to ensure dishes and utensils were properly handled properly after sanitization from the dishwasher. This had the potential to affect all 78 residents if they receive food from the kitchen. *Dietary staff were observed going from the dirty side of the dishwashing machine to the clean side without performing hand hygiene.

Inspectors wroteBased on observation, record review and interview, the facility did not implement an effective Water Management Committee, along with infection prevention with medication administration. This was observed with 1 (R38) of 4 residents observed with medication administration. The facility did not include a closed unit in their water plan, which has the potential to effect all 74 residents in the facility. - The facility has a closed unit with no water assessment to prevent Legionella. - R38's medications were administered in a unsanitary manner.

Inspectors wroteBased on interview and record review, the facility did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 78 Residents who reside in the facility as the 5 CNA's work throughout the building as needed.

Inspectors wroteBased on interview and record review the Facility did not ensure 8 of 8 staff chosen at random received QAPI (quality assurance performance improvement) training on the elements & goals of the Facility's QAPI program which is required for all direct and indirect staff. This practice had the potential to affect all 78 residents in the facility. The following direct care workers: Certified Nursing Assistant (CNA)-CC, CNA-DD, CNA-EE, CNA-FF, CNA-T, and Licensed Practical Nurse (LPN)-R did not receive the required QAPI training within the required time-frame of date of hire. The following indirect care workers Laundry/Housekeeping (LK)-GG and Dietary Aide (DA)-HH did not receive the required QAPI training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received the annual Compliance and Ethics training. This practice had the potential to affect all 78 residents in the facility. The facility did not provide staff with the required annual Compliance and Ethics training which includes all direct and indirect staff for Laundry/Housekeeping (LK-GG) and Dietary Aide (DA-HH) on an annual basis.

Inspectors wroteBased on record review and interview, the facility did not ensure direct care staff 5 of 5 Certified Nurse Aides (CNAs)(CNA-CC, CNA-DD, CNA-EE, CNA-FF, CNA-T), Licensed Practical Nurse (LPN-R), and indirect care staff Laundry/Housekeeper (LK-GG), and Dietary Aide (DA-KK) reviewed received behavioral health training to care for Residents diagnosed with mental, psychosocial, a history of trauma, or substance use disorder as indicated on the facility assessment. This deficient practice has the potential for all staff to lack current knowledge to work with the unique challenges mental health illnesses present. The facility did not provide staff with required annual training on the facility's behavioral health services. Findings Include: The facility's Facility Assessment Tool policy, updated 3/28/24, contains the following information: [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure pressure injury interventions were accurately implemented. This was observed in 1 (R57) of 5 residents reviewed for pressure injuries. *R57 was observed in bed with the air mattress at an incorrect setting.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R10) of 2 residents reviewed received appropriate services related to catheter care. R10 did not have a follow up appointment made as requested to see Urology after a hospitalization on 1/23/2024 per discharge recommendation.

Inspectors wroteBased on observation, record review and interview, the facility did not provide adequate nutritional support to 2 (R21, R66) of 4 residents reviewed for Nutrition. *R21 sustained a weight loss in January 2024. The facility did not follow recommendations from the facility's dietician to implement weekly weights for R21. *R66 sustained a significant weight loss in January 2024. The facility did not follow recommendations from the facility's dietician to implement weekly weights for R66.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure a resident with a gastrostomy tube received the appropriate care and services for 1 (R63) of 2 residents with gastrostomy tubes. R63's water flush bag was not labeled for two days.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure intravenous fluids were administered appropriately. This was observed with 1 (R57) of 1 residents observed with IVF (intravenous fluids). - R57 had a 1 liter bag of 0.9 sodium chloride being infused intravenously with no identifying factors to include name, date, rate, purpose of IVF.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure oxygen humidification was implemented. This was observed with 1 (R57) of 1 resident's observed with oxygen administration. -R57 had orders for oxygen humidification and this was not implemented.

Inspectors wroteBased on interview, and record review, the Facility did not ensure 2 (R72, R66) of 5 residents were free from unnecessary medications. *R72 was prescribed antipsychotic medication without a timely Abnormal Involuntary Movement Scale (AIMS) assessment. *R66 was prescribed antipsychotic medication without a timely Abnormal Involuntary Movement Scale (AIMS) assessment.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles including the expiration date when applicable for 1 of 2 medication carts reviewed and 1 of 1 medication rooms reviewed. *The North team two medication cart also contained containers of eye drops that were either not labeled with an opened date, had an illegible opened date, or were expired. *The East medication room contained 13 bottles of Optum Daily Rescue supplement that were expired 8/2023.

Inspectors wroteBased on interview and record review the facility did not ensure the State Long Term Care Ombudsman was notified when 2 (R10, R51) of 2 residents were reviewed for hospitalizations. 1.) R10 was admitted to the hospital on [DATE], 11/21/2023, 12/28/2023, and 1/23/2023. The facility did not notify the Ombudsman of R10's hospitalizations. 2.) R51 was admitted to the hospital on [DATE], 12/15/2023, and 3/16/2024. The facility did not notify the Ombudsman of R51's hospitalizations.

Inspectors wroteBased on observation, staff interviews, and record review, the facility did not ensure food was stored under sanitary conditions. These deficient practices had the potential to affect 72 of 74 residents residing at the facility. The kitchen was observed to have food debris on the floor and a sticky red residue. Open food items were not labeled and dated with a use by date.

Inspectors wroteBased on observation, interview and record review the facility did not provide residents with meals that were palatable, attractive and served at an appetizing temperature for 72 of 74 residents residing at the facility. Residents expressed dissatisfaction with meals reporting their food was cold, did not taste good and they did not received desired food preferences. Surveyor's sampled lunch tray had food temperatures that were not hot and were not appetizing and/or palatable.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice after an unwitnessed fall for 3 (R54, R71, and R52) of 5 residents reviewed for falls. *R54 had an unwitnessed fall on 9/11/22. Neurological checks were not always completed following the fall to assess for a change in mentation. * R71 had unwitnessed falls on 6/2/2022, 8/13/2022, and 8/22/2022. Neurological checks were not completed following the falls to assess R71 for a change in mentation. * R52 had an unwitnessed fall on 12/15/22. Neurological checks were not always completed following the fall to assess for change in mentation.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents environment remained free of accident hazards or received adequate supervision to prevent accidents for 2 (R67, R71) of 5 residents reviewed for falls. R67 did not have interventions in place that were initiated on 12/29/2022 after a fall. R67's bed was not pushed up against the wall to prevent R67 from slipping out of bed. R71 had a witnessed fall on 10/4/2022. The At Risk for Falls Care Plan was revised on 10/4/2022 with the intervention staff were to walk R71 twice daily. The intervention did not specify which staff were responsible for the intervention. No documentation was found showing this intervention was being done and staff interviewed were not aware of this intervention.