Willows Health and Rehab Ctr

Inspectors wroteBased on closed medical record review and staff interview, the facility failed to timely identify and implement interventions to prevent significant/severe weight loss. Actual Harm occurred when Resident #173 was assessed to have a severe 24.8 pound/13.3 percent (%) weight loss in 30 days without evidence of timely identification of the resident's decreased oral intake or timely intervention to address the cause of the weight loss. On 01/17/24 Resident #173 complained of tooth pain and was discovered to have a loose front tooth. The resident complained of continued pain with a decrease in oral intake. On 01/18/24 Resident #173 weighed 186.2 pounds and the next weight obtained on 02/13/24 was 161.4 pounds which reflected a 24.8 pound (severe)/13.3 % weight loss in under 30 days. This affected one resident (#173) of four residents reviewed for nutrition. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility policy the facility failed to develop comprehensive care plans for residents who were smokers. This affected four (Residents #2, #17, #64, #65) of twenty-one residents reviewed for care plans. The facility census was 65 residents.

Inspectors wroteBased on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure resident care plans with updated with changes in code status. This affected one (Resident #50) of 29 residents reviewed for care plans. The facility census was 65 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate pre-dialysis communication was provided to the dialysis center, failed to ensure the dialysis provider provided the facility with timely post-dialysis information, and failed to respond to concerns from the dialysis center. This affected one (Resident #36) of one resident reviewed for dialysis. The facility census was 65 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #121's pain was managed effectively. Resident #121 sustained actual harm as evidenced by severe pain and depression when physician ordered Fentanyl patches for pain associated with sickle cell anemia was not provided for eighteen days. This affected one of two residents (Residents #121 and #63) reviewed for pain management. The facility census was 71.

Inspectors wroteBased on observation and interview the facility failed to store frozen foods under sanitary conditions. This had the potential to affect all 68 residents receiving food from the facility. There were three resident who were not receiving food from the facility (#45, #52, and #66). The facility census was 71.

Inspectors wroteBased on review of the Quality Assessment and Assurance (QAA) sign-in sheets and staff interview the facility failed to hold quarterly meetings. This had the potential to affect all 71 residents living in the facility.

Inspectors wroteBased on observation, staff interview, review of the facility's Coronavirus, (COVID-19) policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) to prevent the possible spread of COVID-19. This had the potential to affect 21 residents (Resident #14, #21, #24, #27, #31, #32, #33, #41, #42, #43, #44, #46, #48, #54, #58, #64, #65, #171, #172, #173, #174) on the 300 hall. The facility also failed to ensure Legionella water testing laboratory results were addressed in a timely manner. This had the potential to affect 71 residents at the facility. And, the facility failed to ensure infection prevention standards were maintained during wound care. This affected one resident (Resident #62) out of three residents reviewed for pressure ulcer. The facility census was 71.

Inspectors wroteBased on record review and interview the facility failed to verify financial records, account transactions or quarterly statements were maintained for resident funds. This affected five of five residents (#29, #58, #60, #61, and #65) reviewed for resident funds and had the potential to affect 33 residents (#2, #5, #8, #11, #12, #13, #15, #16, #17, #23, #24, #26, #27, #29, #31, #33, #35, #36, #42, #43, #44, #49, #50, #53, #54, #58, #60, #63, #65, #67, #70) whose funds were managed by the facility. The facility census was 71.

Inspectors wroteBased on interview and record review the facility failed to ensure participation of the resident and resident's representative in developing the residents comprehensive care plan. This affected six residents (#4, #10, #30, #45, #52, and #70) of seven residents reviewed for care plan participation. The facility census was 71.

Inspectors wroteBased on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure medications were stored according to manufacture guidelines. This affected four residents (Resident #29, #50, #69 and #171) of 71 residents who resided at the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form were witnessed for residents whose personal funds were being managed by the facility. This affected one Resident (#58) of five residents (#29, #58, #60, #61, and #65) reviewed for personal funds. The facility census was 71.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed following resident discharge. This affected two of two residents reviewed for discharge (Residents #1 and #10) . Facility census was 71.

Inspectors wroteBased on interview and record review the facility failed to have a discharge planning process in place which addressed each resident's discharge goals and included identifying changes in the resident's condition which warranted revising the discharge plan. This affected three of three residents (#4, #10, and #30) reviewed for discharge planning. The facility census was 71.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services to maintain personal and oral hygiene. This affected four (Residents #60, #62, #24, and #44) of 11 residents reviewed for personal hygiene. Facility census was 71.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #62 was treated timely for complaints of abdominal pain. This affected one resident (Resident #62) of one resident reviewed for timely treatment. The facility census was 71.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure splints ordered by the physician were applied for Resident #7 and #62. This affected two residents (Resident #7 and #62) out of three residents (Resident #7, #32, and #62) reviewed for splints. The facility census was 71.

Inspectors wroteBased on interview and record review the facility failed to adequately monitor Resident #45's nutritional status and implement actions to prevent ongoing weight loss. This affected one of two residents reviewed (#45 and #66) for weight loss while on enteral feeding. The facility census was 71.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide dental services for one resident (Resident #62) of two residents (Residents #25 and #62) reviewed for dental concerns. The facility census was 71.

Inspectors wroteBased on observation, taste test, interview and record review, the facility failed to serve room trays at palatable temperatures. This had the potential to affect the 73 residents who usually ate their meals in their rooms. The facility census was 78. Findings Include: Observation on 04/02/19 at 11:28 A.M. of tray line temperatures taken by assistant dietary manager #401 revealed all food temperature taken were within the safe temperature zone for serving. The hot food was held at 135 degrees or higher and the cold food was held at 41 degrees or lower. On 04/02/19 at 11:58 A.M. a test tray was completed. Food temperatures were taken by corporate registered dietitian (RD) #403 and the food tasted by the surveyor and RD #403. The green beans and carrots were 125 degrees tasted warm enough. The potatoes were 105 degrees and did not taste warm enough. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 77 out of 78 residents who received meals from the facility's kitchen. One resident (Residents #42) received enteral nutrition and did not receive meals from the kitchen. The facility census was 78.

Inspectors wroteBased on observation and interview the facility failed to ensure public bathrooms were in safe operating condition. This affected four of five of the bathrooms available to staff and visitors. The facility census was 78.

Inspectors wroteBased upon interview and record review the facility failed to notify the ombudsman's office when Resident #22 and Resident # 88. This affected two of three residents who were reviewed for discharge from the facility to alternate settings. The facility census was 87.

Inspectors wroteBased on interview and record review the facility failed to ensure care conferences were held. This affected one resident of one resident (Resident #17) reviewed for care conferences. The facility census was 87. Findings Include: Review of the medical record revealed Resident # 17 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction, convulsions, chronic kidney disease, major depressive disorder, schizophrenia, anxiety disorder, heart failure, diabetes, atherosclerotic heart disease, alcohol dependence and cocaine dependence. The annual minimum data set (MDS) dated [DATE] revealed Resident #17 required extensive assistance of one person for bed mobility, transfers, walking, locomotion off unit, dressing, toileting and personal hygiene. Supervision was needed for locomotion on the unit. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure its garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 78. Findings Include: Observation of the facilities garbage dumpster area with the assistant dietary manager (ADM) #401 on 04/01/19 at 9:16 A.M. revealed the area was noted to have empty cardboard boxes, disposable gloves, empty containers and other various items around the outside dumpster. ADM #401 verified the above observations at the time of discovery.