Willows Health and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Willows Health and Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 1, 2021

  Based on closed record review, review of the facility policy and procedure related to physician and provider orders, and interviews with facility staff including Regional Director of Clinical Services (RN) #602 and Licensed Practical Nurse (LPN) #603, the facility failed to provide quality care and treatment for one resident (Resident #72) who was readmitted to the facility on [DATE] following hospitalization with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #72 received an ordered respiratory inhaler for [CONDITION(S)] for 12 days, failed to administer a diuretic medication that was ordered to give immediately on [DATE], failed to order an ultrasound of the left leg that was ordered STAT (urgently) on [DATE] and failed to monitor Resident #72's… […]

• Immediate jeopardy, isolatedF760Nov 1, 2021

  Based on closed record review, review of the facility policy and procedure related to physician and provider orders, and interviews with facility staff including Regional Director of Clinical Services (RN) #602 and Licensed Practical Nurse (LPN) #603, the facility failed to ensure one resident (Resident #72) who was readmitted to the facility on [DATE] following hospitalization with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #72 received an ordered respiratory inhaler for [CONDITION(S)] for 12 days and failed to administer a diuretic medication that was ordered to be given immediately on [DATE]. This resulted in Immediate Jeopardy when Resident #72 was found on the floor on [DATE] at 4:00 P.M. […]

• Actual harm, isolatedF692May 23, 2024

  Based on closed medical record review and staff interview, the facility failed to timely identify and implement interventions to prevent significant/severe weight loss. Actual Harm occurred when Resident #173 was assessed to have a severe 24.8 pound/13.3 percent (%) weight loss in 30 days without evidence of timely identification of the resident's decreased oral intake or timely intervention to address the cause of the weight loss. On 01/17/24 Resident #173 complained of tooth pain and was discovered to have a loose front tooth. The resident complained of continued pain with a decrease in oral intake. On 01/18/24 Resident #173 weighed 186.2 pounds and the next weight obtained on 02/13/24 was 161.4 pounds which reflected a 24.8 pound (severe)/13.3 % weight loss in under 30 days. […]

• Actual harm, isolatedF697May 9, 2022

  Based on observation, interview and record review, the facility failed to ensure Resident #121's pain was managed effectively. Resident #121 sustained actual harm as evidenced by severe pain and depression when physician ordered [MEDICATION(S)] patches for pain associated with [CONDITION(S)] was not provided for eighteen days. This affected one of two residents (Residents #121 and #63) reviewed for pain management. The facility census was 71. Findings include: Review of the Resident #121's medical record revealed an admitted [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812May 9, 2022

  Based on observation and interview the facility failed to store frozen foods under sanitary conditions. This had the potential to affect all 68 residents receiving food from the facility. There were three resident who were not receiving food from the facility (#45, #52, and #66). The facility census was 71. Findings include: On 05/02/22 from 9:48 A.M. to 10:06 A.M. a tour of the kitchen was conducted with Certified Dietary Manager (CDM) #284. During the tour one bag of opened, unlabeled, and undated chicken cubes was found in the freezer. The bottom shelf of one storage rack in the freezer was not six inches from the floor. There was hardened spilled liquid, food, and dirt under the rack. There were multiple food containers stored on the bottom shelf. On 05/02/22 at 10:02 A.M. […]