The Willows at Fritz Farm

Based on observation, interview, record review, review of a job description, and review of the facility's policy, the facility failed to revise the comprehensive care plan for 1 of 13 sampled residents (R), R20. R20 had a Velcro lap belt ordered on 12/01/2025 which was discontinued on 12/27/2025. Per an observation and interview, the lap belt was no longer utilized for R20. However, review of R20's Care Plan revealed it was not revised to discontinue the lap belt and was still an active intervention. The findings include:Review of the facility's policy titled, Comprehensive Care Plan Guideline, revised on 05/22/2018 and most recently reviewed on 12/10/2025, revealed that if a previous care plan was no longer needed, it would be resolved from the active care plan.Review of R20's Face Sheet revealed the facility initially admitted the resident on 06/14/2017, and her most recent admission date was 04/21/2026. Her primary diagnosis was chronic obstructive pulmonary disease (COPD) with exacerbation.Review of R20's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of…

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 the facility's policy, the facility failed to ensure that medications and biologicals were stored safely, securely, and properly according to manufacturers' recommendations for medications that belonged to 2 of 33 sampled residents (R), R48 and R32. In addition, two unopened vials of heparin, with no resident identification or directions for use, were observed in the same compartment as the ophthalmic solutions. The findings include:Review of the facility's policy titled, Medication Storage in The Facility, revised 11/2018, revealed medications and biologics are stored at their appropriate temperature and humidity and medications that require refrigeration or a cool place were refrigerated unless otherwise directed. It further revealed when the original seal of a manufacturer's container was broken, the container or vial would be dated, and a date opened sticker shall be placed on the medication. The policy stated, No expired medication will be administered to the…

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, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents reviewed for meal service, Resident (R) 23, R39, and R52.Observation of the meal service on 05/13/2026 at 12:10 PM revealed Licensed Practical Nurse (LPN) 1 did not sanitize her hands between giving trays to residents and the residents' meal setup. In addition, she provided feeding assistance to R23, R39, and R52 using the same, unsanitized hands between each resident. Further observation revealed LPN1 had a personal drink at the table that she drank while providing meal assistance to the three residents. The findings include:Review of the facility's policy titled, Guideline for Handwashing/Hand Hygiene, revised 02/09/2017 and reviewed 11/18/2025, defined hand hygiene as a general term that applied to hand washing or the use of 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, and review of the facility's document and policy, the facility failed to provide a clean, sanitary, comfortable, and homelike environment for 1 of 4 hallways, the 100 Hall. The findings include: Review of the facility's document Trilogy - Kentucky HC admission Packet 10.28.24_Combined, undated, revealed under the Resident Rights section, the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Review of the facility's policy titled, Urinary Catheter Care, dated 12/16/2024, revealed the facility's staff ensured there was no disconnection or leaking of urine from the catheter system. A policy that addressed homelike environment was requested but not provided. Observation on 04/01/2025 at 9:50 AM revealed a slight smell of urine upon entrance to the facility. Observation on 04/03/2025 at 9:47 AM revealed a strong urine smell in the 100 Hall. Observation on 04/04/2025 at 8:32…

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, and review of the facility's document and policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 nourishment refrigerators, near the 300 Hallway. The findings include: Review of the facility's policy titled, Food Labeling and Dating Policy, dated 04/26/2022, revealed it was the purpose of the policy to provide education and direction on the facility's food labeling and dating guidelines. Further review found it was the facility's policy and procedure to place a printed or handwritten label for any food item brought to the facility. Per the policy, this food product label should have the received on date, production date, and the use by date for the product. The policy stated the label should also have the resident's name and the initial of the staff member that made the label. Observation of the refrigerator for residents' food near the 300 Hallway on 04/03/2025 at 9:55 AM and 10:48 AM revealed two opened tubs of pimento cheese with no resident name but…

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 interview, record review, and facility policy review, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 3 of 6 residents reviewed for advance directives, Resident (R) 5, R36, and R42. The findings include: Review of the facility's policy titled, Guidelines for Advance Directives, revised 09/26/2024, revealed its purpose was to ensure the facility's staff obtained and followed residents' advance directives regarding end-of-life care. Further review revealed if a resident had a living will and a durable power of attorney (POA) for health care, these documents would be scanned into the medical record by the admissions representative or designee. 1. Review of R5's Face Sheet revealed the facility admitted the resident on 12/18/2024 with diagnoses including dementia and atherosclerotic heart disease. Further review revealed Family (F) 4 was listed as R5's POA. Review of R5's admission Minimum Data Set [MDS],…

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, record review, and facility policy review, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood. The facility further failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents investigated for hospitalizations, Resident (R) 5 and R10. The findings include: Review of the facility's policy/document titled, Transfer/Discharge - Bed Hold Notification Process, undated, revealed a transfer/discharge notice was to be filled out at the time of transfer or discharge and included in the transfer packet that was sent with the resident. Further review revealed the Social Services Director (SSD) would notify the ombudsman as soon as possible, and this could be done via email. Additional review revealed the Business Office Manager (BOM), or designee would contact the resident/family/Power of…

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, review of the enhanced barrier precaution (EBP) signage from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 out of 6 sampled residents, Resident (R) 31 and R36. 1. Licensed Practical Nurse (LPN) 1 with the aid of Nursing Student (NS) 1 was observed pulling up R36 in bed prior to giving her medications. R36 had signage posted on her door that stated she was on Enhanced Barrier Precautions (EBP) for a pressure ulcer. LPN1 and NS1 only had on gloves when pulling up R36 and did not have on a gown. 2. LPN1 was observed dropping a pill on the top of the medication cart and then picking it up with her ungloved hand and placing it in the pill cup with the other pills for R31.…

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, record review, and review of the Manufacturer's Recommendation for the Stander Be Independent Security Pole, it was determined the facility failed to take appropriate precautions to ensure a safe environment to prevent avoidable accidents for six (6) of thirteen (13) sampled residents (Resident's #5, #6, #9, #11, #25 & #44). Residents #5, #6, #9, #11, #25 & #44 had a transfer pole device installed in their room. The facility failed to ensure the transfer device was installed per the manufacturer's recommendations for safety. The facility failed to adhere to the Manufacturer's Recommendations for the Stander Be Independent Security Pole related to WARNING ENTRAPMENT AND FALLING HAZARD. Per the Manufacturer's Recommendations, when installing the pole next to the bed, couch, toilet or any object, the pole was not to be installed closer than the user(s) ability to safely walk around the pole or there may be a possibility of becoming entrapped between the pole and the side of any object adjacent…

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.