Willow Creek Health Care

Based on observation, record review, and interview, the facility failed to ensure staff wore gloves and cleaned the resident's skin prior to injection for one (#28) of one sample resident observed for insulin injection. The administrator identified 51 residents resided in the facility. An undated facility matrix documented eight residents received insulin. Findings: A Subcutaneous Injections policy, dated March 2011, documented to put on gloves and clean the site with alcohol prior to injection. On 12/10/24 at 11:10 a.m., LPN #1 was observed to inject Resident #28 with insulin. LPN #1 was observed not wearing gloves or cleaning the site prior to injection. On 12/10/24 at 11:11 a.m., LPN #1 stated they should have worn gloves and clean the site prior to injection. They confirmed they did not wear gloves or clean the site prior to injection. On 12/10/24 at 11:33 a.m., RN #2 stated staff should wear gloves and use alcohol on the site prior to injection.

Based on record review and interview, the facility failed to ensure pain management was provided for one (#50) of one sampled resident reviewed for pain management. A Resident Census and Conditions of Residents report, dated 09/25/23, identified 54 residents resided in the facility and 35 residents on a pain management program. Findings: A Pain-Clinical Protocol policy, revised March 2018, read in part .the physician and staff will identify individuals who have pain or who are at risk for having pain .the staff will reassess the individual's pain at least each shift for acute pain or significant changes in levels of chronic pain .review should review frequency, duration, mood behavior, sleep pattern . Resident #50 had diagnoses which included dementia, depression, down syndrome, and stage three pressure ulcer. An admission Assessment, dated 07/17/23, documented the resident's cognition was moderately impaired with daily decision making. A Physician's Order, dated 08/18/23, documented to administer Tylenol 325mg every six hours as needed for pain. A Progress Note, dated 09/01/23 at…

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 record review, observations and interviews, the facility failed to review/revise/implement the care plans for three (#15, 30 and #45) of eight sampled residents reviewed for care plans. This affected: The Resident Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #15 had diagnoses to include major depressive disorder, insomnia, atrial fibrillation and congestive heart failure. A Physician's Order, dated 03/11/22, documented Resident #15 was to be administered bupropion, an antidepressant, 150 mg twice a day for depression. APsychological Services Progress Note[s], dated 08/11/22, 08/18/22, 09/01/22, 09/08/22, and 09/29/22, read in parts, .Current Risk Factors .Suicidal/Self Injury: Ideation . A Physician's Order, dated 10/14/22, documented Resident #15 may have a consult and be treated by mental health for depression. A Physician's Order, dated 10/14/22, documented staff must witness Resident #15 to swallow pills, to check the mouth to make certain pills have been swallowed. A Quarterly Assessment, dated…

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 record reviews, observations and interviews, the facility failed to a. re-assess/monitor and intervene for one (#26) of one sampled resident with a change of condition; and b. follow physician's orders to obtain/monitor weekly weights for four (#30, 34 and #45) of 21 sampled residents reviewed for physician's orders. The Residents Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #26 had diagnoses to include hypertension, cardiac arrhythmia, pacemaker placement, mechanical complications of cardiac electronic device - sequelae, and heart disease. A progress note dated 10/08/22 at 3:00 p.m., read in parts, .complaining of having the fuzzy-wuzzies .taking a shower and dropped his washcloth and bent over to pick it up when he had the 'fuzzy-wuzzies' .vital signs: 170/102, 60 .assisted to get into his wheelchair and taken to his room .still a little unsteady while getting into his wheelchair .was told to lie down in his bed for an hour . The clinical record contained no documentation Resident #26 was…

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 record review, observation, and interview, the facility failed to ensure a PRN psychotropic medications order was limited to 14 days for one (#26) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 27 residents received psychoactive medications. The Census was 49. Findings: Resident #26 had diagnoses to include major depressive disorder, and insomnia. A Care Plan, dated 02/07/18, read in parts, .Psychotropic drug use .Has interrupted Sleep patter r/t insomnia .Restoril (temazepam) 15 mg PO Q HR PRN . A physician order, dated 11/30/18, documented Resident #26 was to be administered temazepam 15 mg every evening for insomnia. The order was discontinued, and a new order written on 09/17/21. A physician order, dated 09/17/21, documented Resident #26 was to be administered temazepam 15 mg PRN at bedtime. The order was discontinued and a new order written on 01/06/22. A physician order, dated 01/06/22 documented Resident #26 was to be administered temazepam 15 mg PRN at bedtime. The order was discontinued 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 record review and interview, the facility failed to have an effective process to formulate/re-evaluate the resident's rights to formulate advance directives. This affected two (#30 and #45) of two sampled residents reviewed for advanced directives. The Resident Census and Conditions of Residents report, dated 11/03/22, documented the census to be 49. Findings: 1. Resident #30 had diagnoses to include dementia, atrial fibrillation with a pacemaker placement, history of myocardial infarction and a history of a fractured femur with sequela. A dated 10/25/20, read in part, DNR. The clinical record did not contain an advance directive. There was no documentation the resident and/or representative had been offered information to formulate an advance directive. 2. Resident #45 had diagnoses to include dementia, respiratory disease, altered mental status, and malnutrition. A Physician Order, dated 10/22/21, read in part, Code Status: Full Code. The clinical record did not contain an advance directive. There was no documentation the resident and/or representative had been offered…

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 record review and interview, the facility failed to notify the physician of changes in condition for one (Resident #26) of one sampled resident reviewed for change of condition. The Resident Census and Condition of Residents, dated 11/03/22, documented the census was 49. Findings: Resident #26 had diagnoses to include hypertension, cardiac arrhythmia, pacemaker placement, mechanical complications of cardiac electronic device - sequel, heart disease, and chondrocostal junction syndrome. A Physician Order, dated 11/09/17, documented resident #26 was to be administered metoprolol tartrate, 25 mg twice a day. The medications was to be held if the systolic blood pressure was less than 110 and/or the diastolic blood pressure was less than 60. A Physician Order, dated 12/01/17, documented Resident #26 was to be administered furosemide 20 mg once a day. The medications was to be held if the systolic blood pressure was less than 110 and/or the diastolic blood pressure was less than 60. A Progress Note, dated 10/03/22 at 8:00 a.m., read in part, .Hospital for pacemaker consult . 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.

Based on record review and interview, the facility failed to develop a comprehensive care plan to include interventions to prevent falls for one (#30) of three sampled residents reviewed for care plans. The Resident Census and Condition of Residents, dated 11/03/22, documented the census was 49. Finding: Resident #30 had diagnoses to include dementia, atrioventricular block, atrial fibrillation, and bradycardia. An Accident/Incident Report, dated 11/16/21, read in parts, .memory impaired .sitting on floor [with] legs under the w/c .moved w/c away from bedside, instructed Resident to call for help when .needs to get up. Showed [Resident #30] where [Resident #30's] call light is . The Fall Care Plan, dated 11/16/21, read in parts, .failed attempt to self transfer .Showed resident call light and to call for help when getting up . An Accident/Incident Report, dated 12/10/21, read in parts, .memory impaired .trying to self-transfer from bed to wc and fell .non-slip socks on, no pants or brief on, wc brakes locked .Remind res to call for assistance . The Fall Care Plan, dated 12/10/21,…

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 record review and interviews, the facility failed to provide interventions to prevent repeated falls for one (#30) of three residents reviewed for falls. The Resident Census and Conditions of Residents, dated 11/03/22, the facility census was 49. Findings: Resident #30 had diagnoses to include dementia, atrioventricular block, atrial fibrillation, and bradycardia. A Significant Change of Status Assessment, dated 02/01/22, documented Resident #30 had experienced one fall with no injury, and two or more falls with skin tears, abrasions, lacerations, superficial bruising, hematoma, and sprains: or any fall-related injury that causes the resident to complain of pain. The comprehensive care plan for falls did not contain interventions to remind the resident to use the call light and request assistance were appropriate. An Accident/Incident Report, dated 05/22/22, read in parts, .sitting on bed room floor .Recommended steps to prevent recurrence .call light for staff to assist to toilet while diarrhea persists . A Fall Care Plan, dated 5/22/22, read in parts, .Failed attempt at…

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 record review, observation and interview, the facility failed to ensure staff were competent to report/follow policy regarding a residents' reports of suicidal ideations with a plan. This affected one (#15) of six sampled resident reviewed for behavioral health and unnecessary medications. The Resident Census and Conditions of Residents, dated 11/03/22, documented the facility census was 49. Findings: The facility's Suicide Threats policy, read in parts, .Resident suicide threats shall be taken seriously and addressed appropriately .staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse .A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident . Resident #15 had diagnoses to include major depressive disorder, insomnia, atrial fibrillation and congestive heart failure. A physician's order, dated 03/11/22, documented Resident #15 was to be administered bupropion, an antidepressant, 150 mg twice a day for depression. A Psychological Services Progress Note[s], dated…

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 record review, observation, and interview, the facility failed to: 1. ensure medication/treatment carts remained locked and keys removed when unattended, and 2. ensure medications that required refrigeration were refrigerated as recommended by the manufacturer for one (#15) of one sampled residents reviewed for refrigerated medications. The Resident Census and Condition of Residents report, dated 11/01/2022, documented 49 residents resided in the facility. Findings: A Security of Medication Cart policy, revised April 2007, read in parts, .Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room . A Storage of Medications policy, revised April 2007, read in parts, .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly . 1. On 11/07/22, at 4:33 p.m., 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.

Based on record review, observation, and interview, the facility failed to ensure staff sanitized the blood pressure cuff after resident use for one (#1) of three sampled residents observed having their blood pressure taken during medication administration. The DON identified 11 residents with infection precautions posted on their room door. The Resident Census and Condition of Residents report, dated 11/01/22, identified 49 residents resided in the facility. Findings: A Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised October 2018, read in parts .resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident . On 11/03/22 at 09:43 a.m., CMA #3 was observed not to sanitize wrist blood pressure cuff after using on prior resident. On 11/03/22 at 10:00 a.m., after gathering resident #1 medications, CMA #3 was observed 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.