Will-O-Bell

In the surveyor’s words

From the most serious findings on record at Will-O-Bell, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 12, 2023

  Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 resident (Resident #1) reviewed for accidents and supervision. The facility failed to ensure the resident was assessed upon admission to the facility to determine if he was safe to smoke independently. The resident started a fire in his room. The facility failed to follow interventions to keep resident staff by supervising resident while he was smoking. An Immediate Jeopardy (IJ) situation was identified on 06/07/2023. […]

• Actual harm, isolatedF580Oct 9, 2023

  Based on interview and record review, the facility nursing staff failed to immediately notify the physician of a significant change in the resident's physical status for 1 of 2 residents reviewed for an unknown injury (Resident #2) LVN B and RN A failed to immediately notify Residents' Physician when a large bruise was discovered on his ankle, which was discovered to be a fracture. This failure may have resulted in Resident #2 experiencing pain from a fracture for 4-5 days. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. […]

• Actual harm, isolatedF607Oct 9, 2023

  Based on interview and record review, the facility staff failed to report to the administrator and/or designee, physician, and failed to investigate an injury of unknown source for 1 of 2 (Resident #2) reviewed for incident reporting. LVN B and RN A failed to reported an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. […]

• Actual harm, isolatedF609Oct 9, 2023

  Based on interview and record review, facility staff failed to immediately, or within 2 hours, report injuries of unknown source to the administrator and/or designee and to other officials for 1 of 2 residents reviewed for an injury of unknown origins (Resident #2) LVN B and RN A did not report an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. […]

• Actual harm, isolatedF689Jul 10, 2023

  Based on interview, and record review, the facility failed to ensure a resident's environment remained as free of accident hazards for (Resident #1) one resident reviewed for transfers. The staff failed to ensure Resident #1 was transferred without a Hoyer lift, resulting in an anterior right shoulder dislocation with associated comminuted fracture. This failure put the residents at risk for falls and injury. Review of Resident #1's face sheet, dated 07/10/2023, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses of hypertension, anemia, kidney disease, and dementia. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 04 indicating a severe cognitive impairment. […]