Willowbrooke Ct Skilled Care CTR at Magnolia Trace

In the surveyor’s words

From the most serious findings on record at Willowbrooke Ct Skilled Care CTR at Magnolia Trace, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 17, 2022

  Based on observations, staff interviews, and review of a facility policy titled, Culinary Services Manual . HAND WASHING PROCEDURE, the facility failed to ensure two Dietary Aides practiced proper handwashing/glove changes when going from touching potentially contaminated objects such as such as the hot box handle to retrieving hamburger buns from a plastic bag and placing them on residents' plates during the lunch meal on 5/14/22. This had the potential to affect 22 of 22 residents receiving meals from the dining room. Findings include: A review of a facility policy titled, HAND WASHING PROCEDURE, with a revised date of 12/07, documented: . POLICY: Each employee will wash their hands frequently to eliminate visible dirt and to reduce bacterial load and cross contamination. 1. […]

• No harm, potential for more than minimal, patternF842Oct 27, 2021

  Based on interviews, resident record reviews, facility documentation of a narcotic audit and a review of the facility's policy titled, Medication, Controlled Substances, the facility failed to ensure licensed staff documented correctly on administration of narcotics on the narcotic log and the Medication Administration Record (MAR). A facility narcotic audit was done of all narcotics on 07/14/2021 revealing: 1.) Employee Identifier (EI) #4, Registered Nurse (RN), failed to document narcotic medication administration on the MAR for Resident Identifier (RI) #3, RI #6, RI #8, RI #9, RI #10 and RI #11; 2.) to document on the narcotic log that narcotics were pulled for RI #2, RI #3, RI #4, RI #5, RI #7, RI #8 and RI #10; 3.) EI #4 document on the MAR only medication for RI #1 that was pulled… […]

• No harm, potential for more than minimal, isolatedF641May 17, 2022

  Based on interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) #32's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/29/22 was accurately coded to reflect RI #32's active diagnoses. This affected one of 13 sampled residents for whom MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: . […]

• No harm, potential for more than minimal, isolatedF880May 17, 2022

  Based on observation, staff interviews, review of facility policies titled, GLOVES AND EYE DROPS, INSTILLATION, the facility failed to ensure: 1. Employee Identifier (EI) #6, a Recreational Assistant, changed gloves and sanitized hands after touching Resident Identifier (RI) #2's wheelchair handles while wearing gloves before she retrieved a plate from the steam table and served it to RI #12 while wearing the same gloves, and 2. EI #7, a Registered Nurse (RN), placed a barrier on the over-bed table before placing a container of eye drops on the table, and changed her gloves and sanitized hands before administering eye drops to RI #8. This affected RI #2 and RI #12, two of 22 residents observed during dining observations, and RI #8, one of five residents observed during medication pass. […]

• No harm, potential for more than minimal, isolatedF658Oct 27, 2021

  Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, and a review of the facility's policy titled, MEDICATION ADMINISTRATION & MANAGEMENT, the facility failed to ensure that Employee Identifier (EI) #4, Registered Nurse (RN), followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 administered [MEDICATION(S)]-Acetaminophen tablet instead of liquid [MEDICATION(S)]-Acetaminophen as ordered to Resident Identifier (RI) #5. […]