The Laurels of Willow Creek

In the surveyor’s words

From the most serious findings on record at The Laurels of Willow Creek, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 24, 2022

  Based on resident interview, clinical record review, facility document review, staff interview and in the course of the medication administration observation, the facility staff failed to follow the physician's orders for 4 of 51 residents in the survey sample, Residents #16, #317, and #217; to include one of five residents in medication administration observation, Resident #9. The findings include: 1. On 11/02/2021 at 10:00 p.m. and on 11/03/2021 at 6:00 a.m., the facility staff failed to follow the physician's order for [MEDICATION(S)], resulting in an overdose. […]

• Actual harm, isolatedF760Mar 24, 2022

  Based on resident interview, clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to ensure a resident was free of a significant medication error for one of 51 residents in the survey sample, Resident #16 (R16). On 11/02/2021 at 10:00 p.m. and on 11/03/2021at 6:00 a.m., facility staff overdosed Resident # 16 R16 by administering 5ml (five milliliters) of [MEDICATION(S)] (1), which was ten times the physician ordered dose, resulting in (R16's) oxygen saturation dropping to 77% and requiring administration of [MEDICATION(S)] (2). The resident was taken to the hospital for further interventions and monitoring. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2022

  Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens. The findings include: On 3/22/22 at 11:54 AM, the Kitchen tour was conducted with OSM #10 (Other Staff Member) the Dietary Manager. The following was noted: At 11:56 AM, food residue was observed on the meat slicer. When asked about this, OSM #10 stated that the meat slicer was supposed to be clean and ready to use, and should not have residue on it. […]

• No harm, potential for more than minimal, patternF656Sep 13, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 37 residents in the survey sample; Residents #100, #88, #91, #87, and #7. The findings include: The facility policy, Care Planning was reviewed. This policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs . 1. […]

• No harm, potential for more than minimal, patternF697Sep 13, 2023

  2. For R7 the facility staff failed to identify the location of the pain, the type of pain and attempts of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1). R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain. R7's comprehensive care plan dated 02/22/2022 documented in part, Need. […]