Inspection Reports for
Life Care Center of the Willows

The facility was found to have multiple deficiencies including failure to maintain resident dignity, inadequate communication about medication changes, incomplete care plans, improper wound care, unsafe smoking practices, failure to provide ordered treatments, improper medication administration, unsafe food handling, infection control lapses, inappropriate antibiotic use, and inadequate water temperature maintenance.

The facility failed to ensure infection control guidelines were implemented properly, including improper use of PPE by staff and confusion about the resident's isolation status. Observations and interviews revealed staff did not wear masks as required and were unaware of the correct isolation precautions for a resident.

This citation relates to Intake 2595565. The complaint involved concerns about incomplete incontinence care documentation and environmental safety hazards.

The facility failed to maintain complete and accurate clinical records for incontinence care for 3 residents, with missing documentation across multiple shifts. Additionally, the environment was found to be unsafe and unclean due to dirty vents, exposed electrical wiring, and a broken baseboard heating cover in multiple areas.

The facility was found not in compliance with emergency preparedness requirements and life safety codes, including failure to conduct required emergency drills, incomplete emergency power system testing, malfunctioning hazardous area doors, improper kitchen appliance safety measures, incomplete fire drill documentation, and inadequate maintenance and testing of electrical equipment.

The facility was found deficient in multiple areas including resident privacy during medication pass, incomplete care plans for pain and opioid use, inadequate pressure ulcer care, failure to provide nutritional supplements and document food consumption, lapses in infection control hand hygiene, and deficiencies in antibiotic stewardship related to delayed follow-up on urine culture results.

Complaint IN00446389 was investigated with no deficiencies related to the allegations cited.

The facility was found deficient in several areas including resident privacy during medication pass, accuracy of Minimum Data Set assessments related to antibiotic use, care plan implementation, pressure ulcer treatment, nutrition/hydration status maintenance, infection prevention during medication pass, and antibiotic stewardship. No deficiencies were cited related to the complaint investigation.

Complaint IN00429836 was substantiated with federal/state deficiencies cited related to the allegations. Resident B reported abuse by a CNA, but the facility did not report the allegation to the Indiana Department of Health as required by state and federal regulations.

The facility failed to ensure an allegation of abuse involving Resident B was reported to the Indiana Department of Health as required. The investigation revealed that Resident B reported being mistreated by a CNA, but the allegations were not reported to the appropriate authorities.

This citation relates to Complaint IN00429836. The allegation involved Resident B reporting abuse by a CNA, which was not reported to the Indiana Department of Health as required.

The facility failed to timely report an allegation of abuse to the Indiana Department of Health for one of three residents reviewed. The allegation involved a CNA removing Resident B's clothes and leaving her in the dining room for three hours. The facility investigated but did not report the allegation as required by state and federal regulations.

The facility was found not in compliance with several Life Safety Code requirements including corridor width obstructions, emergency lighting record keeping, smoke detector maintenance, hazardous area door self-closing, kitchen hood grease trap installation, fire alarm and sprinkler system policies and maintenance, corridor door latching, sprinkler head obstructions, fire watch plan deficiencies, evacuation plan incompleteness, and improper use of power strips and extension cords.

Complaint IN00424101 was investigated and federal/state deficiencies related to the allegations were cited at F677 and F689.

The facility was found deficient in multiple areas including resident self-determination, accuracy of assessments, baseline and comprehensive care planning, ADL care, quality of care including skin and mobility management, accident prevention, nutrition and hydration, medication management including unnecessary drugs and psychotropic medication use, laboratory services, antibiotic stewardship, and environmental conditions.

This inspection relates to Complaint IN00424101 as noted in deficiencies F0677 and F0689 regarding resident care and safety.

The facility failed to honor resident preferences, develop timely care plans, provide adequate assistance with activities of daily living, ensure appropriate treatment and monitoring, maintain safety measures, meet hydration and nutritional needs, manage medications properly including pain management and antibiotic stewardship, and maintain the physical environment in good repair.

Complaint IN00408213 involved allegations of verbal and physical abuse. The allegation was not immediately reported as required. Resident B reported that a CNA told him to get up and get his own water and laughed at him. The Administrator reported the incident as soon as she received it, but the staff member had not alerted her at the time of the event.

The facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator and timely reported to the State Survey Agency for 1 of 3 allegations of verbal and physical abuse reviewed involving Resident B. The staff member delayed reporting the incident, which was only discovered through a Concern & Comment Form found after the fact.

This Federal tag relates to Complaint IN00408213. The allegation involved verbal abuse by a CNA toward Resident B, which was substantiated by interviews and documentation.

The facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator and timely reported to the State Survey Agency. The staff member delayed reporting the concern, which was only discovered after a Concern & Comment Form was found in paperwork.

Complaint IN00406256 was substantiated with federal/state deficiencies cited at F656, F684, F692, and F740 related to care plan development, quality of care, nutrition/hydration, and behavioral health services.

The facility was found deficient in multiple areas including failure to develop and implement person-centered care plans for self-harming behaviors, failure to provide treatment and care according to professional standards related to neurological consults and insulin administration, failure to maintain proper hydration and nutrition, and failure to provide necessary behavioral health services related to increased self-harming behaviors.

The complaint investigation was triggered by Complaint IN00406256, which involved concerns about care planning, treatment adherence, hydration and nutrition, and behavioral health services for residents with complex medical and behavioral needs.

The facility failed to develop and implement complete care plans for self-harming behaviors, provide appropriate treatment and care according to physician orders, ensure sufficient hydration and nutrition, and provide necessary behavioral health care including psychiatric consultation for increased behaviors. These failures contributed to hospital transfers and potential harm to residents.

The facility was found not in compliance with Life Safety Code requirements including deficiencies in fire alarm system maintenance, sprinkler system maintenance and storage, electrical junction box safety, and improper use of power strips in a staff area.

Complaint IN00391790 - Substantiated with no deficiencies cited. Complaint IN00391933 - Substantiated with no deficiencies cited.

The facility was found to have multiple deficiencies including failure to accommodate resident needs, inadequate restraint monitoring, incomplete care plans, failure to apply therapeutic devices, lack of hearing aid monitoring, incomplete pressure ulcer treatment, catheter care issues, nutritional monitoring failures, improper gastrostomy tube medication administration, inadequate bed rail assessments, infection control lapses, and failure to ensure contracted staff COVID-19 vaccination compliance. Environmental concerns included marred walls, missing floor tiles, and duct taped side rails.