The Willows at Springhurst

Based on observation, interview and review of facility policy, the facility failed to prepare, store, and serve food under sanitary conditions for 51 of 52 residents who received food from the kitchen. The findings include: Review of the facility's Hair Restraint Policy' revised date 07/09/2025, revealed all dining service employees were required to wear hair restraints as required by the Federal Food Code, Hair Restraints 2-402.11. Review of the Federal Food Code dated 2009, revealed food employees shall wear hair restraints such as hats, hair covering or nets that are designed and worn to effectively keep their hair from contacting exposed food. Observation, on 09/16/2025 at 2:14 PM, revealed the Cook's hair net was not covering the side or back of her hair. There was approximately eight inches of hair without covering.During interview with the [NAME] at the time of the observation, she stated employees were to wear a hair net that covered all the hair when they were in the kitchen and around food. She further stated, I have a lot of hair. She also stated the facility discussed…

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 refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Pre-admission screening and resident review (PASRR) evaluation for 1 of 1 sampled resident (Resident (R) 5).The findings include: The facility did not provide a policy specific to PASRR evaluation. Review of Resident (R) 5's, Face Sheet revealed the facility originally admitted the resident on 07/01/2022 with the most recent re-admission date of 11/25/2024 with diagnoses including acute and chronic respiratory failure, bipolar disorder, dementia, major depressive disorder, generalized anxiety disorder, and paranoid personality disorder. Review of R5's, Pre-admission Screening and Resident Review (PASRR), dated 07/01/2022 revealed diagnoses of major depressive disorder, generalized anxiety disorder, and dementia. Further review revealed a Level II referral was not indicated at that time. Review of R5's Comprehensive Care…

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 facility policy review, the facility failed to ensure residents were free of any significant medication errors and that medications were received at the right time for 1 of 8 sampled residents (Resident (R) 6).The findings include: Review of the facility policy titled, Medication Administration Times Procedural Guidelines, revised 12/01/2021 and reviewed 12/17/2024 revealed guidelines for determination of medication administration times based on a resident's preference unless a specific time is designated by the attending physician. Review of the facility policy titled, Specific Medication Administration Procedures/Injectable Medication Administration, revised 11/2018 revealed the procedure included guidelines to check the five rights (right patient, right drug, right route, right dose, right time) when medication selected, as dose is prepared, after dose prepared, before medication is put away, and before injection is administered. Review of Resident (R) 6's, Face Sheet revealed the facility admitted the resident on 02/20/2025…

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 policies, the facility failed to follow infection prevention and control practices to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident observed for subcutaneous injection administration. (Resident (R) 6.The findings include: Review of facility policy, Infection Prevention and Control Program, revised 11/15/2021 and reviewed 12/17/2024 revealed its purpose was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections. Review of the facility policy, Specific Medication Administration Procedures/Injectable Medication Administration, revised 11/2018 revealed examination gloves were part of the equipment required for injectable medication administration. Further review revealed procedures for subcutaneous injections included to sanitize hands with approved hand sanitizer and put on gloves prior to…

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 to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed undated and opened containers of salad dressing, and in the freezer unopened vegan trays, and meat and cheese packages. Additional observation of the freezer revealed a container of strawberries covered with a gray substance. Further observations revealed the freezer temperature log was incomplete for the dates of 08/20/2021 through 08/30/2021. The findings include: Review of the facility's policy, Food Labeling and Dating, dated March 2019, revealed any food product removed from its original container, or with a broken seal, or had been processed in any way, would be labeled. Per review, the label was to include the item's name, the date and time the food was labeled, the used by date, and initials of the person labeling the item. Review of the facility's policy titled, Refrigerators, dated May…

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 review of the facility policy, it was determined the facility failed to ensure performance reviews were completed every twelve (12) months, for six (6) of six (6) nurse aides personnel files reviewed. The findings include: Review of the facility's policy, Quarterly Wage Investment Timeline, undated, revealed employee eligibility for increases was dependent on disciplinary actions incurred resulting from performance and performance improvement plans, etc. Review of the facility's Skills Check-Off sheets revealed the facility evaluated employees on Hand Washing, and Guidelines for Donning and Doffing Personal Protective Equipment (PPE). The facility did not provide a policy specific to Nurse Aid performance evaluation. The facility failed to provide documented evidence of performance evaluations of nurse aides for six (6) of six (6) nurse aide files sampled. Interview, on 09/03/2021 at 9:40 AM, with the Staff Development Coordinator (SDC) revealed the nurse aide employment anniversary was utilized to meet training and educational timeframe's. She…

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 facility policy review it was determined the facility failed to ensure resident care plans were implemented for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations from 08/30/3031 through 09/03/2021, revealed no palm guard in place to the resident's right hand as per the Comprehensive Care Plan. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the Comprehensive Care Plan was an interdisciplinary communication tool. Per review, the Comprehensive Care Plan described the services provided to a resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In addition, review revealed the Comprehensive Care Plan was to reflect the care a resident received. Review of the facility's policy, Splints and Orthotic Devices, undated, revealed an orthotic device was used to support 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure quality of care for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations each day of the survey revealed no palm guard present on the resident per care plan intervention and therapy recommendation. The findings include: Review of the facility policy Splints and Orthotic Devices, undated, revealed orthotic devices were used to support a joint or body part, inhibit abnormal tone, reduce pain, or position the joint in a functional position. Orthotic devices were used for joint range of motion, to reduce pain, reduce effects of disease, and reduce risk for skin breakdown or joint deformity. Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the comprehensive care plan (CP) was an interdisciplinary communication tool that described the services provided to a resident to attain or…

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 policy, the facility failed to ensure unused kitchen equipment was removed and disposed of when no longer in use. Observation revealed the outside delivery area of the facility contained six (6) commercial coffee makers/dispensers, two (2) commercial beverage dispensers, an ice chest, a commercial toaster, a countertop microwave, three (3) empty milk crates, a portable gate, a mop and bucket full of liquid, and a wood pallet. The findings include: Review of the facility's policy entitled, Garbage and Refuse, dated 05/31/2016, revealed all garbage and refuse was stored and disposed of daily. Observation, on 09/01/2021 at 8:49 AM, revealed the facility's outside delivery area contained the following: a mop bucket filled with liquid and a mop; six (6) commercial coffee makers/dispensers; two (2) commercial beverage dispensers; three (3) black, empty milk crates; a countertop microwave oven; a blender base; a yellow rolling collapsible gate; a horizontal ice chest; a commercial toaster with rust on the top; a hose sprayer;…

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, review of the facility-wide assessment, CMS Form 672, and policy review it was determined the facility failed to accurately determine the number of residents in the facility with respiratory diagnoses or care needs. Review of the facility's resident population included three (3) residents with tracheostomy care and ten (10) resident who required a closed unit and isolation for COVID-19 care. Review of the facility's assessment found the facility failed to include the residents for the determination of the competent care to meet the needs of the resident population. The findings included: Review of the Facility Assessment Tool, dated 08/18/2017, revealed Long Term Care (LTC) facilities conducted the assessment to document and annually review a facility-wide assessment, which included both their resident population and the resources the facility needed to care for their residents. The purpose included to determine the necessary resources to care for residents competently with…

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 policy review, it was determined the facility failed to ensure safe, operating conditions of the fryer and freezer in the kitchen. Observation on 03/02/2021 at 8:28 AM, revealed two (2) boxes in close proximity to the ceiling of the walk-in freezer. Observation on 03/03/2021 at 1:35 PM, revealed liquid substance on the floor under fryer and four (4) boxes in the walk in freezer within close proximity to the ceiling. The findings include: Review of the document titled, Emergency Operations Plan, Hazardous Materials or Chemical Spills, undated, revealed hazardous materials included substances which were flammable and combustible. The policy revealed the proper steps for facility staff members during a hazardous materials emergency. Review of the document titled, Fryer, undated, revealed the cleaning process for the fryer which included draining the fryer, using cleaning solution, rinsing the fryer twice after cleansing solution, and replacement of oil after the fryer has dried. Review of the documents titled, Aides Cleaning List, dated December 2020…

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.