Willowbend Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Willowbend Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jul 22, 2022

  The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 halls reviewed for infection control. 1. The facility failed to test all residents and staff when Resident #61 tested positive for COVID-19 at the facility. The facility did not test all residents until after the 6th resident tested positive. 61 residents out of 121 residents developed COVID-19. 2. The facility failed to ensure facility staff did not reuse the same cloth gowns on more than one resident. 3. The facility failed to ensure devices used by more than one resident were cleaned and sanitized between uses. 4. […]

• Immediate jeopardy, isolatedF580Jan 17, 2024

  Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for one of five residents (Resident #1) reviewed for notification of changes. -The facility failed to notify the physician when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. -The facility failed to notify Resident #1's RP when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. […]

• Immediate jeopardy, isolatedF684Jan 17, 2024

  Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to notify the physician and provide interventions to monitor and treat Resident #1 when LVN C observed and documented a new wound on his left toe. Resident #1 was high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF600Nov 3, 2023

  Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of three residents reviewed for post-surgical aftercare. The facility failed to ensure Resident #1 received the necessary level of assistance and that staff were aware of physician's orders and PT evaluations to prevent injury. Resident #1 required revision surgery to the right shoulder. The noncompliance was identified as PNC. The IJ began on 09/13/23 and ended on 09/15/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and/or treatment recommended by physician. […]

• Immediate jeopardy, isolatedF600Sep 15, 2023

  Based on observations, interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 24 (Residents #95) residents reviewed for abuse. The facility failed to ensure to ensure CNA A was adequately trained to deescalate Resident #95's aggressive behaviors when CNA A and Resident #95 had a verbal altercation in which CNA A aggressively responded to Resident #95's verbal abuse by calling him a derogatory name and threatened she would spit in his face. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. […]