Willows Post Acute

Inspectors wroteBased on interview, record and policy review, the facility violated Resident 1's right to manage her own financial affairs when the facility applied to have Resident 1's pension checks deposited into a resident fund management service (a bank account managed by a company who handles resident funds), without written authorization from Resident 1. This failure caused Resident 1 anger and frustration by not having control over how she chose to manage her finances.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services that promoted respect and dignity for four of four sampled residents (Resident 1, 2, 3, and 4) when direct care staff did not respond and help residents dependent on staff with their requests for assistance. These failures resulted in residents feeling afraid to ask for assistance, uncomfortable, and unwanted.

Inspectors wroteBased on interview, and record review, the facility failed to contact and consult with the Responsible Party (RP) and the family for Resident 1, a Native American individual with a diagnosis of unspecified dementia (where cognitive decline is present, but the specific type of dementia cannot be identified), regarding cultural practices related to hair. This failure resulted in Resident 1 given a haircut, which was against her family's cultural preferences. During a record review of facility policy titled Brushing and Combing Hair dated 2001 MED-PASS, indicated staff were to review resident's care plan to assess for any special needs of the resident prior to the haircut. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to provide nail care for 1 (Resident #119) of 2 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in accordance with professional standards for food service safety when: 1. A slimy, brown-pink substance was found inside the holding tray of the facility's icemaker. 2. Dirty dishwasher water from the dishwasher's air gap (directs dirty dishwater from a pipe in the dishwasher to a drain in the floor to prevent it from backing up onto clean dishes) was splashing onto floor tiles next to the drain. 3. A kick plate at the bottom of an oven/stove unit was missing, exposing wires and other internal parts. These failures created safety issues for staff and had the potential to cause avoidable food- or waterborne illness for all 68 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable, and homelike environment when: 1. Varnish was worn off the wooden handrails in Unit 1 (hallway between Rooms 27-34 and hallway between Station 1 nurses' desk and patio). 2. Wall paint was scratched or in disrepair in Rooms 6, 10, 30, and 37, and curtains were missing in room [ROOM NUMBER]. These failures violated all (68) facility residents' rights to a clean, comfortable, homelike environment; diminished their quality of life; and increased the potential risk for infection from exposure to germs on uncleanable surfaces.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care to maintain good grooming and personal hygiene for 3 of 19 (Resident 6, 22, 56) sampled residents when: 1. Resident 6 had an unkept beard and mustache and his nails were long and dirty. 2. Resident 56 's and 22's hair was matted and sticking up. These failure had the potential to result in depression, poor self-esteem, denial of resident rights all of which could lead to negative clinical outcomes for these residents. Findings A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting revised March 2018, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely vision services for one of seventeen sampled residents (Resident 416). This failure resulted in continued vision issues and in Resident 416 feeling like giving up on getting his vision problems addressed.

Inspectors wroteBased on interview, and record review, the facility failed to consistently document the location of the pain, failed to administer a dental prescription order for a dental rinse, and failed to follow their pain assessment and management policy and procedure for one of seventeen sampled residents (Resident 416). These failures resulted in dental pain.

Inspectors wroteBased on interview, and record review, the facility failed to ensure social services arranged to provide dental and vision services for one of seventeen sampled residents (Resident 416). This failure resulted in Resident 416 feeling like giving up on getting his dental and vision problems addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate labeling of medications for two (of seven) residents, when: 1. The label for clonidine (a medication to control blood pressure, which is a measurement of the pressure of blood pushing against the arteries as it is pumped through the body) contained partial instructions, a failure with the potential for the medication being given inappropriately which may lead to a dangerously slow heart rate; and, 2. Eye drop solution Visine dry eye relief taken from general stock and used for Resident 38 was found to have been labeled with the resident's first and last initials, and not her name, a failure with the potential for confusion as to the intended recipients and the potential for cross contamination (the transfer of harmful bacteria from one source to another) which could lead to poor health outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely dental services for one of seventeen sampled residents (Resident 416) when he complained of tooth pain. This failure resulted in continued dental pain and in Resident 416 feeling like giving up on getting his bad teeth treated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). This deficient practice did not ensure there was effective oversight of day-to-day dietetic services operations and had the potential to put all residents at risk for unmet nutritional needs, weight gain/loss, and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently incorporate resident preferences for 8 of 68 sampled residents (Residents 31, 28, 51, 41, 56, 416, and two confidential residents) in personal dietary choices. This failure had the potential for all facility residents to eat less food, leading to the potential for weight loss and unmet nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an infection prevention system was implemented when: 1. Medical supplies were found in dirty condition on the floor, and the sink, soap dispenser and towel dispenser were found in dirty condition, in the medication room. 2. Resident 316 was allowed to store and wash her soiled laundry in a shared bathroom that had the potential to spread infection to one of three Residents (Resident 44). 3. Certified Nursing Assistant (CNA) E failed to do hand hygiene with two of two Residents (Resident 15 and 50) when CNA E assisted Resident 15 to the toilet, wiped her, helped her put on clean pullups(disposable underwear) and then assisted with Resident 50 without doing hand hygiene. These failures had the potential for cross contamination (the transfer of bacteria from one source to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of medications for four (of seven residents) when: 1. Licensed Vocational Nurse (LVN) C failed to check expiration dates on medications administered to Resident 44, a failure that could have resulted in ineffective medication or adverse reactions to expired medications, and; 2. LVN D failed to confirm the identities of Residents 39 and 60 before administering medications, a failure that could have resulted in administration of medications to the wrong residents with the potential for harmful health outcomes, and; 3. Eye drops different from those ordered were found to have been pulled from over-the-counter stock for Resident 38, a failure that could have resulted in harmful health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect food and equipment from potential cross contamination when: 1. Staff did not consistently wear or change aprons when moving from dirty to clean tasks. 2. The ice machine was not clean. These failures had the potential to result in foodborne illness from cross contamination between staff clothing, food, and equipment during food preparation, meal service and dish washing processes, and between the ice machine and ice used in food production and served to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently ensure that three of 15 sampled residents (Residents 3, 37, and 20) received food cut to a size to meet their individual needs. This failure had the potential to result in residents choking on food, and decreased meal intake that could negatively impact their nutrient consumption and overall nutrition and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate resident food allergies, intolerance's and preferences for three of 15 sampled residents (Residents 45, 37, and 207). This failure had the potential to result in decreased nutrition intake, decline in health, and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) system when: 1. The committee did not ensure that the nursing staff accurately recorded percentages of meals eaten for two of 15 sampled residents (Residents 36, and 43), and 2. The committee did not monitor the effectiveness of their plan to detect weight variances for two of 15 sampled residents (Residents 43, and 208). This failure had the potential to lead to undetected weight loss which could have threatened the residents' health and well-being leading to negative clinical outcomes.