Brickyard Healthcare - Willow Springs Care Center

In the surveyor’s words

From the most serious findings on record at Brickyard Healthcare - Willow Springs Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 12, 2023

  Based on interview and record review, the facility failed to ensure a resident was free from neglect when a facility staff member failed to thoroughly assess the resident, report accurate information to the management staff regarding the resident's condition, and notify the physician timely when the resident experienced a change of condition for 1 of 3 residents reviewed for neglect (Resident B). Resident B coded and was sent to the hospital where she later passed away. The Immediate Jeopardy began on [DATE], between 8:00 and 8:30 a.m., when a CNA noticed Resident B was not responding as normal and went to the Assistant Director of Nursing (ADON) office for help after she had notified LPN 1 and did not feel LPN 1 took her seriously. […]

• Actual harm, isolatedF686Jan 5, 2022

  Based on interview and record review, the facility failed to provide care and services to an existing pressure injury which was identified on admission from the hospital, but not thoroughly assessed, monitored, and preventative and treatment orders obtained, to prevent the worsening of the existing pressure injury or 1 of 3 residents reviewed for pressure injury. (Resident E) Finding includes: The record for Resident E was reviewed on 1/3/2022 at 1:40 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 11/17/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF689Mar 27, 2023

  Based on observation, interview and record review, the facility failed to ensure smoking paraphernalia (cigarettes, lighters, matches) were stored with facility staff between smoking times for 5 of 9 residents reviewed for accident hazards. (Residents 12, 48, 10, 119, 22) Findings include: 1. During a random observation, on 03/20/23 at 10:41 a.m., Resident 12 was observed to have a pack of cigarettes stored in a stocking on his left leg. During an observation, on 03/20/2023 at 10:15 a.m., Resident 12 was observed propelling himself in a wheelchair towards his room. At the top of his sock, was tucked a red package of cigarettes. The record for Resident 12 was reviewed on 03/24/23. […]

• No harm, potential for more than minimal, patternF921Mar 27, 2023

  Based on observation, interview and record review, the facility failed to maintain a sanitary homelike environment for 6 of 6 residents observed for environment. (Resident 65, 67, 170, 39, 18 and 58) Findings include: 1. During an observation, on 03/21/23 at 8:41 a.m., Resident 65's room was found to have debris (trash) on the floor. 2. During an observation, on 03/20/23 at 11:32 a.m., Resident 67's room was found to have debris and food on the floor. 3. During an observation, on 03/23/23 at 9:32 a.m., Resident 170's room was found to have used wet towels and wash cloths on the floor by the door. During an interview, on 03/23/23 at 9:33 a.m., License Practical Nurse (LPN) 2 indicated dirty linens were not to be left on the floor. 4. […]

• No harm, potential for more than minimal, patternF584Jan 10, 2023

  Based on observation, interview and record review, the facility failed to ensure temperatures of resident rooms were maintained at a temperature of 71-81 degrees Fahrenheit for 7 of 71 occupied rooms reviewed for comfortable temperatures. (Rooms 210, 208, 225, 236, 237, 334 and 310) Findings include: During a walk-through of the facility, on 01/10/2023 beginning at 9:10 a.m., with the Maintenance Director in attendance the following resident rooms were found to be below 71 degrees Fahrenheit. a. room [ROOM NUMBER] was found to have a temperature of 70 degrees Fahrenheit. b. room [ROOM NUMBER] was found to have a temperature of 70.6 degrees Fahrenheit. c. room [ROOM NUMBER] was found to have a temperature of 70.5 degrees Fahrenheit. d. […]