The Willows at Citation

In the surveyor’s words

From the most serious findings on record at The Willows at Citation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 26, 2025

  Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure staff observed required hand hygiene practices during the plating of food for the meal service. This deficient practice had the potential to affect 45 current residents who received meals from the kitchen. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, with a review date of 01/01/2023, revealed it was the purpose of the policy to prevent the spread of infection from one person to another. […]

• No harm, potential for more than minimal, patternF761Nov 4, 2021

  Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for two (2) out of two (2) medication storage rooms, and one (1) out of three (3) medication carts. Observation of the [NAME] hall medication room refrigerator revealed the refrigerator's temperature was thirty-two (32) degrees Fahrenheit. Continued observation of the refrigerator's temperature revealed the temperature was thirty-four (34) degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, patternF812Nov 4, 2021

  Based on observation and interview, it was determined the facility failed to ensure proper sanitation procedures to prevent the outbreak of foodborne illness. Observation during the initial kitchen tour revealed two (2) large steam table pans stored wet, leading to the potential for bacterial growth. The findings include: Observation, on 11/02/2021 at 9:00 AM, revealed two (2) steam table preparation pans stored wet on a shelf near the steam table, stacked among five (5) other steam table preparation pans. Other serving ware on the shelf was observed to be dry. Interview with the Dietary Manager (DM), on 11/02/2021 at 2:56 PM, revealed normally, all dishes were placed onto a cart to air dry; but, there was limited space and the line had to keep moving. […]

• No harm, potential for more than minimal, isolatedF628Jun 26, 2025

  Based on interview and record review, the facility failed to provide the resident representative with written notification of the resident's transfer to the hospital for 1 out of 5 sampled residents, Resident (R) 14. The findings include: Review of R14's Face Sheet revealed the facility admitted the resident on 07/16/2024 with diagnoses of hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and hyperlipidemia. Review of R14's hospital Discharge Summary, dated 01/08/2025, revealed she had been hospitalized on [DATE] for vomiting blood and was diagnosed with a pyloric obstruction and a urinary tract infection. […]

• No harm, potential for more than minimal, isolatedF656Nov 4, 2021

  Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and/or implement a person centered Comprehensive Care Plan (CCP) for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (3) of eighteen (18) residents; Resident #38, Resident #29, and Resident #12. 1. Review of the CCP for Resident #29 revealed the resident demonstrated exit seeking behaviors and a wander guard would be applied as appropriate. […]