Willowbrooke Court SKD Care Center at Lima Estates

In the surveyor’s words

From the most serious findings on record at Willowbrooke Court SKD Care Center at Lima Estates, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Jun 10, 2022

  Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for one of 13 residents reviewed (Resident 35). Findings include: Review of Resident 35's clinical record revealed a physician's order dated January 5, 2022, for [MEDICATION(S)] (narcotic pain reliever) Patch 72 Hour 12 micrograms/hour - Apply 1 patch transdermally (to the skin) every 72 hours for pain and remove per schedule and an order dated August 4, 2021, to check the placement of the patch every shift. […]

• No harm, potential for more than minimal, isolatedF689Jun 10, 2022

  Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure two of 13 residents reviewed received adequate supervision resulting in an elopement and a fall during a transfer using a lift (Residents 33 and 35). Findings include: Review of facility policy Elopement/Wandering Risk Assessment reviewed June 13, 2022, revealed that When responding to an alarm, if it cannot be determined what triggered the alarm, immediately verify that every resident is safe and accounted for by conducting a visual head and name reconciliation Review of Resident 33 progress notes dated June 1, 2021, at 11:46 p.m. revealed Approx. 7 p.m. […]

• No harm, potential for more than minimal, isolatedF610May 13, 2021

  Based on a review of clinical records and facility policy and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse and injury of unknown origin for three of 14 residents reviewed (Closed Record Residents CL1, CL2, and Resident 12) Finding include: A review of the facility's policy and procedure titled Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Property Prevention, with a revision date of October 2019, revealed that the executive director, administrator, or designee will immediately initiate an investigation of the alleged incident and include the following: Type of allegation being reported; Resident's description of the abuse, neglect, mistreatment, exploitation, or misappropriation of property;… […]

• No harm, potential for minimal, widespreadF730May 13, 2021

  Based on a review of employee personnel records and staff interview, it was determined that the facility failed to complete annual performance reviews for five of five Nurse Aides reviewed (Employee E4, E5, E6, E7 and E8). Findings include: A list of Nurse Aides provided by the facility for review failed to reveal that the following employees had an annual performance review completed by the facility: Employee E4 (Date of Hire-March 11. 2019), Employee E5 (Date of Hire - November 22, 2011), Employee E6 (Date of Hire- June 14, 2016), and Employee E7 (Date of Hire-April 19, 2011), and Employee E8 (Date of Hire-February 11, 1988) An interview with the Nursing Home Administrator on May 12, 2021, at 3:00 p.m. […]