Inspection Reports for
Willowbend Health and Rehabilitation, LLC
830 Canal Street, Marion, AR, 72364
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Arkansas average
Arkansas average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 7
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, PASARR screening, care planning, accident hazard prevention, medication storage, food service, and overall facility safety and sanitation.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments for hospice and dialysis, failure to complete PASARR screening prior to admission, incomplete person-centered care plans for residents, inadequate supervision leading to resident injury, expired medications stored in medication carts, failure to prepare and serve meals according to the planned menu, and poor food storage and sanitation practices including unclean ice machines and improper hand hygiene by dietary staff.
Deficiencies (7)
Failed to accurately indicate hospice care and dialysis on Section O of the Minimum Data Set (MDS) for sampled residents.
Failed to ensure PASARR screening was completed prior to admission for a sampled resident.
Failed to develop and implement complete person-centered care plans for residents including COVID-19 precautions, antibiotic interventions, and contact precautions.
Failed to ensure adequate supervision and proper transfer techniques resulting in a resident's dislocated shoulder; Immediate Jeopardy identified but corrected prior to survey.
Failed to ensure medications stored in medication carts were not expired, including narcotics.
Failed to prepare and serve meals according to the planned menu, including incorrect portion sizes and missing items for residents on special diets.
Failed to maintain food storage areas with covered, sealed, and dated food items; failed to maintain clean ice machines; dietary staff failed to wash hands before handling food; and hot food items were served below required temperatures.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Expired medications: 13
Residents on mechanical soft diet: 21
Temperature of ground turkey: 125
Temperature of pureed bread: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Failed to use correct lift and assistance causing resident injury |
| CNA #10 | Certified Nursing Assistant | Assisted CNA #1 during improper transfer of Resident #25 |
| RN #11 | Registered Nurse | Assessed Resident #25 after injury and notified Nurse Practitioner |
| Director of Nursing | Director of Nursing (DON) | Confirmed importance of accurate MDS and care plans; confirmed transfer failure and injury |
| MDS Coordinator | MDS Coordinator | Confirmed inaccuracies in MDS hospice and dialysis sections and care plan omissions |
| Dietary Manager | Dietary Manager | Confirmed food storage and sanitation deficiencies; acknowledged ice machine residue |
| RN #21 | Registered Nurse | Observed expired medications in medication cart #1 |
| RN #17 | Registered Nurse | Observed expired medications in medication cart #2 |
| ADON | Assistant Director of Nursing | Handled discontinued narcotics and medication destruction |
| CNA #12 | Certified Nursing Assistant | Observed leaving hazardous items accessible to residents; cleans ice machine monthly |
| DC #2 | Dietary Cook | Prepared insufficient portions and failed hand hygiene |
| DC #3 | Dietary Cook | Failed hand hygiene and used unclean utensils during food service |
| DA #4 | Dietary Aide | Handled condiments and supplements with bare hands and contaminated glasses |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to neglect and safety hazards, including inadequate supervision leading to a resident injury and unsafe storage of hazardous items accessible to residents.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy due to neglect in resident transfer procedures causing injury, and other deficiencies related to safety hazards and food service violations.
Findings
The facility was found to have immediate jeopardy related to inadequate supervision and failure to use proper transfer equipment, resulting in a resident's dislocated shoulder. Additional findings included unsafe storage of hazardous items accessible to residents, failure to prepare and serve meals according to the planned menu, and multiple food safety and sanitation violations.
Deficiencies (4)
Failure to ensure adequate supervision and proper transfer techniques, resulting in Resident #25 sustaining a dislocated right shoulder.
Failure to ensure hazardous items such as aerosols, medications, perfumes, and creams were not accessible to residents, risking accidental exposure.
Failure to prepare and serve meals according to the planned menu, including incorrect portion sizes and missing items for residents on special diets.
Failure to maintain food safety standards including uncovered, unsealed, and undated food items; unclean ice machines; improper handwashing and glove use by dietary staff; and inadequate cleaning of kitchen equipment.
Report Facts
Residents affected: 1
Residents affected: 15
Residents affected: 8
Residents affected: 21
Temperature: 125
Temperature: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Failed to use correct lift and proper assistance during resident transfer causing injury |
| CNA #10 | Certified Nursing Assistant | Assisted in improper transfer of Resident #25 and provided interview details |
| RN #11 | Registered Nurse | Assessed Resident #25 after injury and coordinated medical evaluation |
| Director of Nursing | Director of Nursing (DON) | Confirmed failed practices and implemented corrective actions |
| Administrator | Facility Administrator | Confirmed failed practices related to Resident #25 injury |
| Dietary Manager | Dietary Manager | Provided multiple interviews and confirmed food safety and sanitation deficiencies |
| DC #2 | Dietary Cook | Observed preparing meals with incorrect portions and improper hygiene |
| DC #3 | Dietary Cook | Observed using unwashed utensils and contaminated gloves during food preparation |
| DA #4 | Dietary Aide | Handled condiments and glasses with bare hands contaminating meal trays |
| CNA #12 | Certified Nursing Assistant | Observed leaving hazardous items accessible and responsible for ice machine cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Mar 28, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding resident care, documentation accuracy, infection control, and adherence to physician orders at Willowbend Health and Rehabilitation, LLC.
Complaint Details
The complaint investigation included allegations of failure to provide dignified care, inaccurate documentation, inadequate assessments, failure to prevent decline in residents' conditions, failure to follow physician orders, failure to provide timely medication and incontinence care, and failure to follow infection control protocols. Immediate jeopardy was identified related to the care of Resident #368 who died following respiratory distress and inadequate response by staff.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inaccurate documentation of discharge assessments, incomplete resident assessments, inadequate care planning, failure to provide timely and appropriate care for residents with contractures and nail care needs, failure to properly assess and respond to a resident in respiratory distress resulting in death, delayed medication administration, failure to provide timely incontinence care, and failure to follow infection control protocols including PPE use and hand hygiene.
Deficiencies (11)
Failure to honor residents' rights to dignity and privacy during care.
Failure to accurately document discharge Minimum Data Set assessment.
Failure to accurately assess resident on Annual Minimum Data Set as required.
Failure to provide services to minimize further decline in range of motion for a resident with contractures.
Failure to review and revise a resident's care plan with participation of resident's representative.
Failure to provide fingernail and toenail care for a resident requiring assistance.
Failure to fully assess a resident in respiratory distress, follow physician's orders, and timely notify physician, resulting in resident death.
Failure to ensure timely administration of medications received at home.
Failure to provide appropriate care to maintain or improve range of motion for a resident with limited ROM.
Failure to provide timely incontinence care, risking skin breakdown and infection.
Failure to follow infection prevention and control protocols including proper PPE use and hand hygiene, risking spread of infection.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Staff trained: 24
Staff trained: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to properly assess and respond to Resident #368 in respiratory distress |
| DON | Director of Nursing | Interviewed regarding care standards, assessments, and infection control |
| CNA #2 | Certified Nursing Assistant | Named in inappropriate discussion at bedside and failure to sanitize hands between glove changes |
| CNA #4 | Certified Nursing Assistant | Named in inappropriate discussion at bedside and failure to sanitize hands between glove changes |
| CNA #7 | Certified Nursing Assistant | Named in failure to wear proper PPE in COVID isolation room |
| CNA #8 | Certified Nursing Assistant | Named in failure to wear proper PPE in COVID isolation room |
| CNA #9 | Certified Nursing Assistant | Interviewed about interventions for residents with hand contractures |
| RN #1 | Registered Nurse | Interviewed about respiratory distress incident with Resident #368 |
| MDS Coordinator | Named in documentation and care plan deficiencies | |
| Social Services Director | Named in care plan meeting scheduling and representative contact | |
| Administrator | Interviewed regarding policies and incident response | |
| Medical Director | Interviewed regarding medical oversight and response to Resident #368 incident | |
| APRN | Advanced Practice Registered Nurse | Named in coordination of medication and medical orders |
| Infection Preventionist | Interviewed regarding infection control policies and PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to review and revise a resident's care plan with family participation, failure to properly assess and treat a resident in respiratory distress resulting in death, and failure to continue medications received at home for another resident.
Complaint Details
The complaint investigation substantiated failures in care planning involvement, assessment and treatment of respiratory distress, and medication continuation. Immediate jeopardy was identified related to the respiratory distress incident resulting in resident death. The facility implemented a removal plan and staff training to address the issues.
Findings
The facility failed to involve a resident's representative in care plan meetings, failed to timely assess and follow physician orders for a resident in respiratory distress leading to immediate jeopardy and death, and failed to ensure continuation of a critical medication for another resident. The facility implemented a removal plan and staff training to address these issues.
Deficiencies (3)
Failed to review and revise a resident's care plan with participation of the resident's representative for 1 of 111 residents.
Failed to fully assess a resident experiencing respiratory distress in a timely manner, failed to follow physician's order during an acute incident, and failed to notify the physician of the change in condition in a timely manner for 1 of 3 residents, resulting in immediate jeopardy and resident death.
Failed to ensure medications received at home were continued after admission for 1 resident.
Report Facts
Residents reviewed for care plan deficiency: 111
Residents sampled for change in condition: 3
Oxygen saturation: 33
BIMS score: 0
BIMS score: 12
BIMS score: 15
Medication cost: 1000
Staff trained: 24
Staff trained: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in respiratory distress incident and documentation |
| RN #1 | Registered Nurse | Supervisor on duty during respiratory distress incident |
| DON | Director of Nursing | Interviewed regarding respiratory distress incident and medication issue |
| Administrator | Notified of immediate jeopardy and involved in removal plan | |
| ADON | Assistant Director of Nursing | Involved in grievance resolution and removal plan |
| MDS Coordinator | Interviewed about care plan meeting scheduling and family contact | |
| Social Services Director | Interviewed about care plan meeting scheduling and family contact | |
| Medical Director | Interviewed about change in condition and medication orders | |
| APRN | Advanced Practice Registered Nurse | Confirmed awareness of medication delay and coordination |
| CNA #1 | Certified Nursing Assistant | Witnessed respiratory distress incident and family interactions |
| Infusion Nurse | Confirmed medication delay for Resident #105 |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including accuracy of assessments, range of motion maintenance, catheter care, respiratory care, and nutritional services.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set assessments, failure to consistently use positioning devices for residents with contractures, inadequate catheter care, improper oxygen therapy administration and storage, and failure to follow the planned written menu for meals.
Deficiencies (5)
Failed to ensure Minimum Data Set assessments were accurate and complete for residents with siderails and pressure ulcers.
Failed to ensure splints, hand rolls, or positioning devices were consistently used to prevent decline in range of motion for residents with contractures.
Failed to provide necessary catheter care including securing catheter with leg strap and proper placement of catheter bag, and failed to provide timely incontinent care.
Failed to ensure respiratory care including proper storage of updraft masks, administration of oxygen at correct flow rates, and oxygen therapy orders.
Failed to ensure meals were prepared and served according to the planned written menu, including incorrect vegetable substitution and inadequate portion size of chicken.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Serving size: 4
Serving size: 2.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided information on safety device evaluation and facility policies | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding oxygen therapy orders and catheter care | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding resident contracture and positioning devices | |
| Certified Nursing Assistant (CNA) #1 and #2 | Observed performing catheter care and interviewed about catheter bag placement | |
| Certified Nursing Assistant (CNA) Supervisor (CNA #3) | Notified about resident needing incontinent care | |
| Dietary Manager (DM) | Interviewed regarding menu substitutions and portion sizes | |
| Restorative Certified Nursing Assistant (CNA) #2 | Interviewed regarding restorative services and hand roll use | |
| Director of Nursing (DON) | Interviewed regarding facility policies on positioning and mobility |
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