Accel at Willow Bend

In the surveyor’s words

From the most serious findings on record at Accel at Willow Bend, in the surveyor’s own words.

• Immediate jeopardy, patternF692May 20, 2023

  48560 Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #58 and #28) of seven residents reviewed for significant weight loss, in that: 1. […]

• Immediate jeopardy, patternF693May 20, 2023

  48560 Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for one (Resident #58) of the four residents reviewed for enteral tube feeding, in that: 1. Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58. 2. […]

• Actual harm, patternF600Jan 9, 2024

  Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of 10 residents reviewed for abuse. CNA A, who was assigned to Resident #1 for the night shift from 12/31/23 to 1/1/24 failed to provide care or check on Resident #1 during the entire shift from 10:00 PM 12/31/2023 - 6 AM 1/1/2024 and CNA B who failed to provide care on her shift from 6 AM 1/1/2024 to 10:22 AM 1/1/24. As a result, Resident #1 was not provided incontinent care or repositioned for over 13 hours on 12/31/23 9:05 PM to 01/01/24 at 10:22 AM. […]

• Actual harm, patternF607Jan 9, 2024

  Based on interview and record review, the facility failed to implement written policies and procedures to prevent abuse to ensure residents were free from abuse for one (Resident #1) of 10 residents reviewed for abuse. 1) The facility deprived goods abuse for Resident #1. 2) CNA B, LVN C, LVN D, and Staffing Coordinator reported an allegation of abuse and neglect on 01/01/24 to the Administrator, who is the Abuse Coordinator immediately when they found Resident #1 soaked in urine and bowel movement. These failures could affect the residents by placing them at risk for a delay in intervention and Providing ADL care including incontinent care and life-saving treatments that could lead to psychosocial harm. […]

• Actual harm, patternF677Jan 9, 2024

  Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of 10 residents reviewed for ADLs. The facility failed to provide incontinent care to Resident #1 for 13 hours on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. CNA A was assigned to Resident #1 and failed to provide care to Resident #1 on night shift. Resident #1 was not provided incontinent care for over 13 hours (including 8 hours of night shift of 12/31/23 and part of 1/1/24 day shift) on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. […]