Willow Wood at Woldenberg Village

In the surveyor’s words

From the most serious findings on record at Willow Wood at Woldenberg Village, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 21, 2023

  Based on observation, interviews and record reviews the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #1) of 3 (Resident #1 Resident #2, and Resident #3) sampled residents investigated for abuse. The facility's noncompliance resulted in actual harm on 11/03/2023 when Resident #2 bit Resident #1 on the right arm area above the wrist resulting in the resident screaming in pain with a visible bite and teeth marks on the skin requiring first aid treatment. Findings: Review of the facility's Abuse and Neglect Policy revealed, in part, residents must not be subjected to abuse including abuse from other residents. […]

• No harm, potential for more than minimal, patternF689Jul 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to: 1. ensure the facility completed evaluations after a resident sustained a fall per policy (Resident #17 and Resident #75); 2. ensure a resident's care plan was revised with new individualized interventions after a resident sustained a fall (Resident #17 and Resident #75); 3. ensure oxygen tanks were secured and not free standing (Resident #102). This deficient practice was identified for 3 (Resident #17, Resident #75, Resident #102) of 5 (Resident #6, Resident #17, Resident #31, Resident #75, Resident #102) sampled residents reviewed for accident hazards. […]

• No harm, potential for more than minimal, patternF695Jul 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Nebulizer Machine (a machine that turns liquid medicine into a mist, allowing it to be inhaled directly into the lungs) Cleaning policy and procedure, dated 11/04/2014 revealed, in part, nebulizer machines and equipment should be kept clean and the nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. […]

• No harm, potential for more than minimal, patternF761Jul 10, 2024

  Based on observations and interviews, the facility failed to ensure insulin (a medication used to lower blood sugar) was discarded within 28 days of the date it was opened on 1 (Cart a) of 3 (Cart a, Cart b, and Cart c) medication carts observed for medication storage. Findings: Observation on [DATE] at 10:30 a.m. of medication cart a, Resident #42's Insulin Aspart Pen 100 unit/1millimeter had an open date of [DATE] and was available for use. Further observation revealed Resident #97's Lantus Solostar (Insulin Glargine) Pen 100unit/1millimeter had an open date of [DATE] and was available for use. In an interview on [DATE] at 10:29 a.m., S2Licensed Practical Nursing (LPN) confirmed the dates written on Resident #42 and Resident #97's insulin pens as [DATE]. […]

• No harm, potential for more than minimal, patternF812Jul 10, 2024

  Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure raw chicken was thawed in a sanitary manner; 2. Ensure the walk in cooler was kept clean and sanitary; 3. Ensure the walk in freezer was free of excessive ice accumulation; and, 4. Ensure water temperature and the concentration level of the sanitizing solution in the facility's 3 compartment sink and dishwasher were monitored and at the level required per the manufacture's guidelines. Findings: 1. Observation of the facility's kitchen on 07/08/2024 at 8:33 a.m. revealed a metal container which contained raw chicken submerged in water. In an interview on 07/08/2024 at 8:40 a.m., S3Chef confirmed the above mentioned raw chicken was submerged in water to thaw and should not have been. […]