The Willows at Harrodsburg

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 18, 2024

  Based on interview, record review, review of MapQuest, and review of the facility's policy, the facility failed to adequately supervise and ensure protection from accidents and injuries for 1 of 20 supplemental and sampled residents, Resident (R) 20. On 10/11/2024, R20 was assisted to bed with two Certified Resident Care Assistants (CRCA) using a mechanical lift. The resident was then re-positioned in bed with one CRCA, CRCA5. CRCA 5 rolled R20 away from her, which resulted in the resident being rolled off the bed and onto the floor. R20 sustained bilateral femur fractures. She was sent to the local emergency roiagnom on [DATE]. On 10/16/2024, R20 underwent surgical repair with Open Reduction and Internal Fixation (ORIF) of her bilateral femurs. […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, interview, and facility policy review, the facility failed to serve food in a sanitary manner. Observation of the kitchen revealed dietary staff with unrestrained hair, which affected 42 of the 43 current residents in the facility that received food from the kitchen.The findings include:Review of the facility's policy titled, Hair Restraint Policy, reviewed date 07/09/2025, revealed, All Dining Service employees will be required to wear hair restraints as required by the 209 Federal Food Code; Hair Restraints 2-402.11 Effectiveness. Review of the policy provided by the facility titled, FDA Food Code 2009: Chapter 2 - Management & Personnel, revealed, Hair Restraints 2-402.11 Effectiveness. […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2024

  Based on observation, interview, and review of the facility's policy, the facility failed to store and safely serve food. Observations on [DATE] at 9:49 AM and 11:12 AM revealed a case of bananas was left sitting directly on the floor, and staff continued to walk around the case. Observation on [DATE] at 2:30 PM revealed the medication room on the 200 Hall had one expired open case of TwoCal supplements with a use-by-date of [DATE]. The findings include: Review of the facility's Serve Safe policy titled, Food Storage, dated [DATE], revealed the best practice was to store food in designated clean food storage areas, away from walls, and at least six inches off the floor. Per the policy, food was to be stored away from dust and other possible contaminants. 1. […]

• No harm, potential for more than minimal, patternF880Dec 18, 2024

  Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to have an effective system in place to implement infection control practices for 2 of 20 sampled and supplemental residents, Resident (R) 1 and R19 and 1 of 2 medication room refrigerators on the 300 Hall. Observations during the survey revealed 1) a nurse touched a resident's medication with bare hands; 2) there was not enhanced barrier precautions signage or a personal protective equipment (PPE) cart at Resident (R) 1's room; 3) R1's gastrostomy (g-tube) dressing change was completed by the nurse without enhanced barrier precautions (EBP) used; and 4) the 300 Hall medication room nutritional refrigerator… […]

• No harm, potential for more than minimal, patternF880Jul 28, 2021

  Based on observation, interview, review of the facility's handout, review of the facility's policies, and review of the Centers for Disease Control and Prevention, Healthcare Providers Clean Hands Count for Healthcare Providers, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. […]