Willowdale Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmision of communicable disease and infection when 6 nursing staff (Licensed Practical Nurse (LPN)-G, LPN-L, Registered Nurse (RN)-I, Certified Nursing Assistant (CNA)-H, CNA-J, and CNA-K) did not complete required COVID-19 testing during a COVID-19 outbreak. This practice had the potential to affect all 25 residents residing in the facility. The facility had a COVID-19 outbreak that started on 1/14/26 and was still active on 2/11/26. LPN-G, LPN-L, RN-I, CNA-H, CNA-J, and CNA-K did not test for COVID-19 every other day and document the results in accordance with the facility's policy prior to working their scheduled shifts.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not notify a Power of Attorney (POA) or family representative of a change in condition for 3 residents (R) (R33, R20, and R6) of 6 sampled residents. R33 passed away on 1/27/26. R33's family was not notified of R33's passing in a timely manner. R20 was diagnosed with COVID-19 on 2/2/26 and was moved to a private room for isolation protocol. R20's POA was not notified of the diagnosis or room change until 2/4/26. R6 was diagnosed with COVID-19 on 1/29/26. R6's POA was not notified of the diagnosis until 2/5/26.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment was completed accurately for 2 residents (R) (R8 and R4) of 5 sampled residents. R8's MDS assessment, dated 1/27/26, did not indicate R8 had a serious mental illness. R4's MDS assessment, dated 11/13/25, did not indicate R4 had a serious mental illness.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R8 and R4) of 5 sampled residents suspected of having a mental illness and/or intellectual/developmental disability were screened through the Pre-admission Screening and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. The facility did not ensure completion of PASRR Level II Screens for R8 and R4.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive resident-centered dementia care plan was implemented for 1 resident (R) (R17) of 3 sampled residents. R17 had diagnoses of dementia and Alzheimer's disease. R17's comprehensive care plan did not contain dementia disease-related goals or interventions for care.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R5) of 1 sampled received the necessary care and services to prevent the development of pressure injuries and/or promote healing. R5 was admitted with stage 3 pressure injury on the left buttock and had an order for a pressure reducing mattress to be set at 150 pounds. During observations on 2/9/26, 2/10/26, and 2/11/26, R5's pressure reducing mattress was set at 200 pounds.

Inspectors wroteBased on staff interview and record review, the facility did not review and revise a care plan intervention for 1 resident (R) (R2) of 2 sampled residents. On 10/27/24, R3 alleged R2 hit R1 on the forearm in the doorway of the dining room. The facility implemented an intervention to serve R2 meals in R2's room or anywhere R2 preferred other than the dining room. There were no monitoring interventions to ensure R2 wasn't being secluded from other residents. In addition, the intervention was meant to be short term but was not removed from R2's care plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One medication cart was observed unlocked and unattended. In addition, 1 of 2 medication carts and 1 of 1 medication storage room contained expired medications and medical supplies. This practice had the potential to affect more than 4 of the 30 residents residing in the facility. The Chestnut hall medication cart (medication cart 1) and the medication storage room contained expired medications and medical supplies. In addition, the Chestnut hall medication cart was unlocked and unattended on 10/1/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written policies and procedures that prohibit mistreatment, neglect, and abuse of residents were consistently implemented for 1 of 8 staff reviewed during the caregiver program compliance check. Certified Nursing Assistant (CNA)-K indicated on CNA-K's Background Information Disclosure (BID) form that CNA-K lived out of state prior to moving to Wisconsin in June of 2024. The facility did not complete an out-of-state background check prior to CNA-K's hire on 7/9/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R23) of 3 sampled residents. The facility did not report an allegation of mistreatment involving R23 to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R23) of 3 sampled residents. The facility did not thoroughly investigate an allegation of mistreatment involving R23 and Certified Nursing Assistant (CNA)-J.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 resident (R) (R15) of 16 sampled residents. R15 had a history of bipolar disorder and dementia with psychotic features. R15's Quarterly MDS assessment, dated 8/17/24, indicated R15 did not have delusion or hallucinations.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 1 resident (R) (R182) of 2 residents with indwelling catheters. During an observation on 9/30/24, R182's uncovered catheter drainage bag was attached to R182's wheelchair and in contact with the floor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the provision of treatment and services to prevent weight loss for 1 resident (R) (R17) of 1 sampled resident. R17 was admitted to the facility on [DATE] and had a significant weight loss of 7.38% between 8/30/24 and 9/17/24. The facility's Registered Dietitian (RD) and physician were not notified following R17's weight loss and interventions were not put in place.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Multiple food items were expired, not dated, and/or not sealed properly. The dessert served for lunch on 11/7/23 was not maintained at the proper temperature during meal service and was not covered prior to service. A microwave and stove top were not kept in a clean condition. Multiple items were not stored 6 inches off the floor. The facility did not have testing logs for sanitizer buckets or the internal temperature of the dishwasher. The facility did not maintain a temperature log for the residents' refrigerator.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 4 Residents (R) (R10, R16, R25, and R5) of 13 sampled residents met the PASRR (Pre-admission Screen and Resident Review) requirements. R10's medical record indicated R10 had mental illness diagnoses upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen when R10 remained in the facility long term. R16's medical record indicated R16 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen when R16 remained in the facility long term. R25's medical record indicated R25 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide a safe, clean, comfortable, home-like environment for 2 Residents (R) (R1 and R17) of 13 sampled residents. During an observation of R1's room, Surveyor noted a large hole in the wall behind R1's recliner. During an observation of R17's room, Surveyor noted a section of molding approximately 4 inches wide and 1.5 feet long hanging off the lower portion of R17's bathroom wall.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R24, R21, R7) of 13 sampled residents met the PASRR (Pre-admission Screening and Resident Review) requirements. R24 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R24 received a qualifying diagnosis and was prescribed medication. R21's PASRR Level I Screen indicated R21 did not have mental illness. A Level II Screen was not completed when R21 received a qualifying diagnosis and was prescribed medication. R7 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R7 received a qualifying diagnosis and was prescribed medication.

Inspectors wroteBased on observation, and staff and resident interview, the facility did not ensure menu items were served according to the extended menu for 2 Residents (R) (R7 and R3) of 2 residents with Level 1 puree texture diets. R7 and R3 did not receive dessert with lunch on 11/6/23. R7 and R3 did not receive a dinner roll with lunch on 11/7/23. During lunch service on 11/7/23, staff used an incorrect scoop size to serve pureed corn.