Continuing Healthcare at Willow Haven

In the surveyor’s words

From the most serious findings on record at Continuing Healthcare at Willow Haven, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 8, 2024

  Based on record review, review of the facility's timeline and related investigation, review of staff education records, resident interview, staff interview, and policy review, the facility failed to ensure nursing staff were adequately trained and knowledgeable on the use of Negative-Pressure Wound Therapy (NPWT) (wound vac) and were able to maintain, monitor, and intervene appropriately when complications arose. They also failed to implement a physician's order to obtain a CT scan and refer a resident to a surgeon when he showed signs of an infected abdominal wound. This affected one resident (#10) of one resident reviewed for wound vac therapy management. […]

• Actual harm, isolatedF689May 18, 2023

  Based on observation, record review, interview, and policy review, the facility failed to ensure fall interventions were implemented and failed to complete a comprehensive fall investigation after a fall resulting in serious injury. Actual Harm occurred on 01/15/23 when Resident #28, who was assessed to have moderate cognitive impairment, required extensive assistance of one staff member for toilet use and transfers and was identified as a fall risk, was instructed by staff (while in the bathroom with the resident) to transfer from the sink to the toilet without staff assistance and while wearing improper footwear, resulting in a fall. The resident sustained a fractured left femur (thigh bone) and possible nondisplaced fracture of the left wrist. […]

• Actual harm, isolatedF689Aug 12, 2022

  Based on record review and interview the facility failed to provide adequate supervision and assistance to Resident #7 to prevent a fall with injury. Actual Harm occurred on 08/01/22 when Resident #7, who was cognitively impaired, required extensive assistance from two staff for toileting and transfers and was at high risk for falls was left unattended on a bedside commode. The resident fell off the bedside commode while unsupervised and sustained a deep cut above her eye requiring six stitches. This affected one resident (#7) of three residents reviewed for falls. […]

• Actual harm, isolatedF686Aug 4, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to develop and implement a comprehensive pressure ulcer prevention program to timely identify, assess and treat a new pressure ulcer to Resident #5's scrotum. Actual Harm occurred on 07/17/22 when Resident #5's family requested the resident be transferred to the hospital for an evaluation of a skin injury to his scrotum. The facility had no assessment or treatment to the area in place prior to the hospital transfer. Hospital records identified a scrotal ulcer, provided pressure ulcer treatment orders and orders for an antibiotic for scrotal infection and the resident returned to the facility the same day. […]

• Actual harm, isolatedF686Jul 22, 2021

  Based on observation, record review and interview the facility failed to prevent the development of pressure ulcers, failed to ensure pressure ulcer prevention interventions were in place prior to the development of pressure ulcers and/or failed to ensure pressure ulcer treatments were completed as ordered. Actual Harm occurred on 07/14/21 when Resident #1 was assessed to have an in house acquired avoidable deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) to the left heel and unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcers to the bilateral buttocks. […]