Willow Ridge Center

Based on facility policy review, observation and interview, the facility failed to maintain a sanitary environment in the kitchen, with the potential to affect 72 of 74 residents in the facility. The findings include: Review of the facility policy titled Equipment revised 9/2018, showed .All foodservice equipment will be clean, sanitary, and in proper working order .All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials .All staff members will be properly trained in the cleaning and maintenance of all equipment .All food contact equipment will be cleaned and sanitized after every use .All non-food contact equipment will be clean and free of debris . During the initial kitchen tour observation on 5/30/2023 at 10:35 AM, with the Certified Dietary Manager (CDM), the stove was found with splashed brown food debris build up on both doors and the right handle of the oven. Observation of the convection oven had dried spattered brown food debris present on the right front of the oven adjacent to the control panel, a copious…

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 facility policy review, observations and interviews, the facility failed to provide a safe, clean, and homelike environment for 1 Resident (#55) of 39 residents reviewed, failed to maintain the upkeep of painted walls in 2 of 4 hallways, failed to maintain the integrity and cleanliness of 2 speciality chairs of the 30 speciality chairs in the facility, failed to provide a safe, clean, and homelike environment for 1 of 1 shower rooms, and failed to provide a safe, clean, and homelike environment for 1 of 1 dining rooms. The findings include: Review of the facility policy titled Accommodation of Needs revised 2/1/2023, showed .The resident .has the right to a safe, clean, comfortable and homelike environment .The Center must provide: A safe, clean, comfortable, and homelike environment . Resident #55 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Viral Hepatitis C, and Osteomyelitis of Vertebra. Review of Resident 55's quarterly Minimum Data Set (MDS) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review and interview, the facility failed to revise the comprehensive care plan for 1 Resident (#53) to include pressure ulcer interventions of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled Person-Centered Care Plan revised 10/24/2022, showed .Care plans will be .revised by the interdisciplinary team .as needed to reflect .care and changing needs . Review of the facility policy titled Skin Integrity and Wound Management revised 2/1/2023, showed .Staff will continuously observe and .implement revisions to the plan of care as needed . Resident #53 was admitted to the facility on [DATE] with diagnoses including Intertrochanteric Fracture of Left Femur, Metabolic Encephalopathy, Muscle Weakness, Type 2 Diabetes, Mild Cognitive Impairment, Need for assistance with Personal Care and History of Falling. Review of a physician's telephone order dated 5/2/2023, showed .Apply sure-prep [a fast drying skin protectant] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review and interview, the facility failed to investigate a fall for 1 Resident (#53) of 3 falls reviewed. The findings include: Review of the facility policy titled Falls: Care During and After dated 12/01/2006, showed .All residents who experience a fall will receive .investigation of the cause .Complete Resident Fall Investigation Form . Review of the facility policy titled Falls Management revised 6/15/2022, showed .A fall is defined as .coming to rest on the .floor .a fall is considered to have occurred when a patient is found on the floor . Resident #53 was admitted to the facility on [DATE] with diagnoses including Intertrochanteric Fracture of Left Femur, Metabolic Encephalopathy, Muscle Weakness, Type 2 Diabetes, Mild Cognitive Impairment, History of falling, and Frontal Lobe and Executive Function Deficit. Review of a nursing note dated 3/4/2023, showed Resident #53 was observed sitting on the floor in the resident's room, .when asked resident what…

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 facility policy review, medical record review, observation and interview, the facility failed to follow the facility policy to obtain a physician's order for an indwelling urinary catheter to include catheter care for 1 resident (#46) and failed to obtain a physician's order for the bulb size of an indwelling urinary catheter for 1 resident (#71) of 3 residents reviewed for catheter use. The findings include: Review of the facility policy titled Catheter: Indwelling Urinary [a tube placed in the bladder to allow urine to drain freely] -Insertion Of reviewed 9/24/2012, showed .Urinary catheters will be inserted in accordance with a physician's order .Verify physician's order .Attach the pre-filled, sterile syringe to the balloon port of the catheter .gently instill the appropriate amount of sterile water/solution (e.g. [for example] 5 cc [cubic centimeter] for 5 cc balloon] .Document: Catheter size, type, and amount of solution used to inflate balloon . Review of the facility policy titled Catheter:…

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 facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for wound management, for 1 resident (#214) of 20 residents reviewed for care plans. The findings include: Review of the facility policy titled ,Person-Centered Care Plan, dated 7/1/2019, showed .A comprehensive, individualized care plan will be developed for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs . Resident #214 was admitted on [DATE] with diagnoses including Sepsis, Cellulitis of Left Lower Limb, Hypertension, Muscle Weakness, and Cognitive Communication Deficit. Review of a physician's order dated 11/15/2021, showed .Clean non viable tissue to L [left] calf with wound cleanser. Apply xeroform gauze [a petrolatum based gauze]. Secure with kerlix [bandage roll] and ace [an elastic bandage] daily . Review of a nurse practitioner's progress note dated 11/17/2021, showed .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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medications were stored and administered safely for 1 resident (Resident #33) of 7 residents observed and reviewed for medication administration when a nurse left the resident's medication at the bedside unattended. The findings include: Review of the facility policy titled, Medication Administration: General, revised 6/1/2021 showed .provide a safe, effective medication administration process .Remain with patient until administration is complete. Do not leave medications at the patient's bedside . Resident #33 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Respiratory Failure with Hypoxia, Shortness of Breath, Major Depressive Disorder, Muscle Wasting, and Contractures of Right and Left Knee. Review of the Minimum Data Set (MDS) 5 day assessment dated [DATE], showed Resident #33 had a Brief Interview for Mental Status…

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 review of facility policy, job description, observation, and interview, the facility failed to maintain a safe, functional, and comfortable environment for 1 of 38 resident rooms observed. The findings include: Review of the facility policy titled, Preventive Maintenance, dated 6/2007 showed .Perform preventive maintenance on .physical plant on a schedule which factors in operational activity and complies with applicable code requirements . Review of the Maintenance Director's job description dated 10/6/2016, showed .The Maintenance Director is responsible for overall maintenance operation of the center .he is responsible for performing repairs .performing regular daily, weekly, and monthly maintenance checks, as shown on 'Preventive Maintenance Calendar' .Maintains the building in good repair .free of hazards .Maintains the building .in compliance with Federal, State, and local laws . Observation of room [ROOM NUMBER]b on 12/5/2021 at 11:56 AM, showed a large hole in the wallboard behind the bed 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 facility policy review, observation, and interview, the facility failed to store clean pans and kitchen equipment under dry sanitary conditions; failed to ensure an expired food additive, expired food items and expired emergency water supply was not available for resident use in 1 of 1 kitchen observed. The findings include: Review of the facility Food and Nutrition Services Policy and Procedures entitled Receiving, with a revised date of 5/2014, revealed .It is the center policy that safe food handling procedures .will be practiced in the .storage of all food items .All food items will be stored in a manner that [insures] appropriate and timely utilization .Foods considered unsafe for consumption or beyond the expiration date will be discarded by staff . Observation and interview with [NAME] #1 on 5/19/19 at 9:00 AM, in the kitchen, revealed 4 of the 8 inch by 12 inch pans, and 2 of the 4 inch by 12 inch pans were stored wet. Continued observation revealed the meat slicer with dry debris; 75 (1) gallon jugs of the emergency water supply with a use by date of 4/22/19 and 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 medical record review, review of facility documentation, review of Activities of Daily Living (ADL) records, resident, family, and staff interviews the facility failed to maintain adequate staffing levels to meet the care needs of 2 residents (#5, #39) of 19 sampled residents and failed to ensure medications were administered timely for 1 resident (#47) of 4 residents observed for medication administration. The findings include: Review of the facility policy, Activities of Daily Living (ADLs), revision date 11/28/16, revealed .Activities of daily living (ADLs) include .Hygiene-bathing . grooming .To attain or maintain the patient's highest practicable physical, mental, and psychosocial well being .receives necessary services to maintain good .grooming, and personal .hygiene . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Muscle Wasting, Acquired Absence of Unspecified Foot, Acute Kidney Failure and Major Depressive Disorder.…

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 facility policy review, medical record review, review of the facility's Activities of Daily Living Record (ADL), observations and interviews, the facility failed to provide scheduled showers for 2 dependent residents (#5, #39) of 13 residents reviewed for ADLs of 19 sampled residents. The findings include: Review of the facility policy Activities of Daily Living (ADLs),with a revision date of 11/28/16, revealed .Activities of daily living (ADLs) include .Hygiene-bathing . grooming .To attain or maintain the patient's highest practicable physical, mental, and psychosocial well being .receives necessary services to maintain good .grooming, and personal .hygiene . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Quadriplegia, Muscle Wasting, Acquired Absence of Unspecified Foot, Acute Kidney Failure and Major Depressive Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to administer oxygen therapy as ordered for 1 resident (#47) of 6 residents reviewed for oxygen therapy of 19 residents sampled. The findings include: Review of the facility policy Oxygen revised 12/1/18 revealed .Set liter flow per order .Attach prescribed oxygen delivery device. Apply oxygen delivery to the resident . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Encounter for Palliative Care, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease, Major Depressive Disorder and Anxiety Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff bed mobility, transfers, and supervision set…

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 facility policy review, medical record review, observation and interview, the facility failed to ensure 2 medications were administered per Physician's Orders of 31 opportunities observed for 1 resident (#47) of 4 residents observed for medication administration resulting in an 6.45% medication error rate. The findings include: Review of the facility's policy, Medication Administration: General, revised date 7/24/18 revealed .A licensed nurse .will administer medications to patients. Accepted standards of practice will be followed. Further review revealed .Practice Standards .Doses will be administered within one hour of the prescribed time unless otherwise indicated by the prescriber . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Essential Hypertension, Major Depressive Disorder, Anxiety Disorder and Encounter for Palliative Care. Medical record review 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.