The Willows at Citation

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure staff observed required hand hygiene practices during the plating of food for the meal service. This deficient practice had the potential to affect 45 current residents who received meals from the kitchen. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, with a review date of 01/01/2023, revealed it was the purpose of the policy to prevent the spread of infection from one person to another. Further review revealed it stated that hand washing was the most important method of infection prevention and control, and hands should be washed after doing cleaning tasks, before and after eating, when using the restroom, or any other task that provided an opportunity for infection. Per the policy, gloves should be worn when encountering items that were intended to be used by a resident. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, dated 03/20/2017, revealed handwashing was the single…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident representative with written notification of the resident's transfer to the hospital for 1 out of 5 sampled residents, Resident (R) 14. The findings include: Review of R14's Face Sheet revealed the facility admitted the resident on 07/16/2024 with diagnoses of hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and hyperlipidemia. Review of R14's hospital Discharge Summary, dated 01/08/2025, revealed she had been hospitalized on [DATE] for vomiting blood and was diagnosed with a pyloric obstruction and a urinary tract infection. Review of R14's Nursing Notes, dated 01/08/2025, revealed R14 returned to the facility via the Emergency Medical Technicians (EMT) after being seen at the Emergency Room, on 01/08/2025, for coffee ground emesis and abdominal pain. Further review revealed the emergency room (ER) had removed 1000 milliliters of gastric contents via a nasogastric (NG) tube, gave her intravenous (IV)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for two (2) out of two (2) medication storage rooms, and one (1) out of three (3) medication carts. Observation of the [NAME] hall medication room refrigerator revealed the refrigerator's temperature was thirty-two (32) degrees Fahrenheit. Continued observation of the refrigerator's temperature revealed the temperature was thirty-four (34) degrees Fahrenheit (F). There was no covering for the freezer compartment to keep cold air from escaping into the refrigerator portion of the unit. Additionally, there was not a separate thermometer for the freezer compartment. Further observation revealed there were four (4) boxes of Influenza Fluzone stacked on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined the facility failed to ensure proper sanitation procedures to prevent the outbreak of foodborne illness. Observation during the initial kitchen tour revealed two (2) large steam table pans stored wet, leading to the potential for bacterial growth. The findings include: Observation, on 11/02/2021 at 9:00 AM, revealed two (2) steam table preparation pans stored wet on a shelf near the steam table, stacked among five (5) other steam table preparation pans. Other serving ware on the shelf was observed to be dry. Interview with the Dietary Manager (DM), on 11/02/2021 at 2:56 PM, revealed normally, all dishes were placed onto a cart to air dry; but, there was limited space and the line had to keep moving. She stated dietary staff panicked when surveyors came in and did not place the pans on the cart to air dry as they were supposed to, and the dietary aides currently working were new. She stated she had been checking all day long to ensure it had not happened again. The DM stated the concern for leaving pans wet was that it created an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and/or implement a person centered Comprehensive Care Plan (CCP) for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (3) of eighteen (18) residents; Resident #38, Resident #29, and Resident #12. 1. Review of the CCP for Resident #29 revealed the resident demonstrated exit seeking behaviors and a wander guard would be applied as appropriate. Review of Progress Notes in October 2021, revealed ongoing assessment of need for wander guard; however observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wander guard. 2.Review of the CCP for Resident #38 revealed his/her preferred activity (s) were music, news via television, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to ensure an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (1) of eighteen (18) residents, Resident #38. There was no documented evidence Resident #38 participated in his/her preferred activities in August, September, October or November of 2021. Record review revealed the resident attended and participated in minimal activities during the last four (4) months at the facility and he/she had not been consistently offered news via television, music, religous or group activities even though the activity(s) were assessed as his/her preferred activities, and were offered on the facility's monthly activity calendar. In addition, observation of Resident #38, on 11/02/2021, 11/03/2021, and 11/04/2021, revealed the resident was in his/her room, in bed with the lights dimmed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed ensure residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and Physicaian's Orders to meet eahc resident's physical, mental and psychosocial needs for one (1) of eighteen (18) sampled resident, Resident #12. The findings include: Review of facility policy titled Guidelines for General Wound and Skin Care, dated 05/23/2018, revealed the purpose of the policy was to provide measures to promote and maintain good skin integrity. Per policy, procedures followed included perform wound treatment and date, time, initial all dressings at time of application. Review of facility policy titled Pressure/Stasis/Diabetic Wound Guidelines, dated 05/10/2016, revealed the policy did not address following physician treatment orders. Interview with the Director of Health Services (DHS), on 11/03/2021 at 11:31 AM, revealed the facility failed to have a written policy or protocol related to following physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of eighteen (18) residents; Resident #29. On 05/15/2021, the facility assessed the resident to be an elopement risk and to require a wandering system bracelet/device on his/her body. Review of the resident's Progress Notes, Care Plan and interviews with staff revealed the resident had wandering behaviors present; however, State Survey Agency (SSA) observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wandering system bracelet/device on his/her body per Physician's Orders. The findings include: Interview with the Executive Director, on 11/04/2021 at 8:30 AM, revealed the facility failed to have a policy to outline the procedure and policy related to accident hazard risk(s) including risk for elopement. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility's polciy, it was determined the facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan for two (2) of eighteen (18) residents. Observations of Resident #35 and Resident #42 on 11/02/2021 and 11/04/2021 revealed their oxygen tubing was unlabeled and there was no signage in place indicating oxygen was in use in accordance with the facility's policy. Further observation of Resident #42 revealed the tubing was crimped and the humidifier was without moisture. The findings include: Review of the facility's policy, Guidelines for properly Administering Oxygen and any Respiratory procedure, revealed that the steps for the initial application of oxygen include placing a No Smoking/Oxygen in Use sign on the outside of the room entrance door. Further review of the policy revealed that the tubing should be dated for the date it was initiated, then should be changed monthly and as needed. Review of the policy additionally revealed that a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.