Inspection Reports for
Willard Care Center

Complaint 2665069 regarding failure to notify families of resident health changes, falls, and new physician orders; substantiation status not explicitly stated.

The facility failed to ensure notification to the resident's family or responsible party of changes in condition for four residents, including falls and new medication orders. Staff did not document family notifications as required, despite multiple incidents and interviews confirming the lack of communication and documentation.

Complaint 2651756 triggered the investigation. The complaint involved medication errors related to ferrous sulfate administration frequency. The report does not explicitly state substantiation status.

The facility failed to keep residents free from significant medication errors when staff administered ferrous sulfate daily instead of weekly as ordered for 82 days. The error was due to incorrect input of physician orders into the electronic Medication Administration Record (eMAR), and staff did not notice the discrepancy despite documentation showing daily administration instead of the prescribed weekly schedule.

The facility failed to ensure residents maintained acceptable nutritional status by not following up and implementing Registered Dietitian (RD) recommendations for supplementation and fortified foods for multiple residents. Several residents with wounds or underweight status did not receive recommended supplements timely. The Dietary Manager and Director of Nursing did not consistently implement or communicate RD recommendations, and documentation of diet orders and supplements was inconsistent.

The complaint involved allegations of possible abuse between two residents that were not reported timely to the state agency and not fully investigated by the facility. The facility failed to hotline the incident and failed to complete investigations as required.

The facility failed to timely report allegations of possible abuse involving two residents to the state agency and failed to fully and timely investigate all allegations of possible abuse. Staff did not report or document the abuse allegations properly, and the facility did not complete investigations or notify the state as required.

The complaint involved one resident (Resident #1) whose laptop was missing after a room move. The resident reported the missing laptop to staff, but the facility delayed reporting to the State Survey Agency until 12/05/24, beyond the required 24-hour timeframe. The facility also failed to notify local law enforcement. The investigation was incomplete, lacking documentation of interviews and police reports.

The facility failed to protect a resident from misappropriation of property when a laptop listed on the resident's inventory was missing. Additionally, the facility failed to report the allegation to the State Survey Agency within the required timeframe and did not notify local law enforcement. The investigation into the missing laptop was incomplete and lacked timely and thorough documentation.

The facility was found deficient in multiple areas including failure to provide an appropriate wheelchair for one resident, failure to electronically transmit MDS assessments timely for three residents, inadequate range of motion care for one resident, improper respiratory care and lack of physician order for oxygen for one resident, failure to meet psychosocial needs of one resident with depression, medication administration errors affecting two residents, failure to address dental needs of one resident, and lapses in infection prevention practices by housekeeping staff.

The facility failed to use appropriate infection control measures, as staff did not consistently perform hand hygiene before and after glove use during peri-care and incontinence care for residents. Observations and interviews confirmed multiple instances of staff not washing or sanitizing hands as required.