WILLOW PARK HEALTH CARE CENTER
For profit - Corporation
151 Beds
SOUTHWEST LTC
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#280 of 282 in OK
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Willow Park Health Care Center has received a Trust Grade of F, indicating significant concerns regarding care quality and safety. Ranked #280 out of 282 facilities in Oklahoma, this places them in the bottom tier, with only three other homes in the state performing worse. Although the facility is improving, having reduced issues from seven in 2024 to one in 2025, it still faces serious challenges, including $40,541 in fines, which is higher than 76% of state facilities. Staffing is rated as below average, with a turnover rate of 61%, which is concerning for continuity of care. Specific incidents include a critical failure to supervise a resident while smoking, leading to burns, and a lack of proper documentation for advance directives for several residents. While there are some improvements in trend, the overall situation remains troubling, indicating a need for careful consideration by families.
- Trust Score
- F
- In Oklahoma
- #280/282
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $40,541 in fines. Higher than 58% of Oklahoma facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 1%
Review needed
7 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Oklahoma average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 61%
15pts above Oklahoma avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $40,541
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: SOUTHWEST LTC
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Oklahoma average of 48%
The Ugly 18 deficiencies on record
1 life-threatening
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to provide adequate assistance to prevent a lift accident for 1 (#3) of 3 residents reviewed for accidents.
The administrator r...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to provide adequate assistance to prevent a lift accident for 1 (#3) of 3 residents reviewed for accidents.
The administrator reported 78 residents resided at the facility.
Findings:
On 05/28/25 at 11:07 a.m., Resident #3 was observed in their room sitting in their wheelchair.
A policy Lifting Machine, Using a Portable, dated December 2013, showed the purpose of the procedure was to help lift residents using a manual lifting device. The policy showed two nursing assistants were required to perform the procedure.
A quarterly assessment, dated 02/13/25, showed Resident #3 was moderately impaired with cognition. The assessment showed the resident was dependent on staff for assistance with activities of daily living. The assessment showed the resident had diagnoses which included multiple sclerosis, paralytic syndrome, lack of coordination, and tremors.
A progress note, dated 04/17/25 at 5:07 p.m., showed ADON #1 responded to an incident with Resident #3. The note showed the resident was assessed while still on the floor after the lift tilted while staff was transferring the resident. The note showed Resident #3 did not feel the staff member was at fault but needed additional education on transferring with the lift. The note showed a family member had viewed camera footage and reported the resident did not fall hard and could see the staff member lower the resident to the floor.
On 05/28/25 at 11:10 a.m., Resident #3 reported there had been one incident when the lift tipped over and fell on them. The resident reported they were not injured and were not afraid of the lift.
On 05/28/25 at 1:17 p.m., CNA #1 reported it was standard procedure and facility policy to have two people use the lift when transferring residents.
On 05/28/25 at 1:25 p.m., LPN #1 reported it was standard practice to have two people when using the lift while providing care to residents.
On 05/28/25 at 1:40 p.m., RN #1 reported the facility had a few residents who required the lift and it was always a two-person assist.
On 05/29/25 at 7:07 a.m., CNA #2 reported they couldn't remember the name of the aide who used the lift without a second person assist, but CNA #2 was called in to replace the aide when they were suspended after the incident with Resident #3. CNA #2 reported lifts were always used with two people.
On 05/29/25 at 8:15 a.m., ADON #1 reported CNA #3 came and got them to let them know Resident #3 was on the floor after the lift tilted. The ADON reported CNA #3 was able to lower the resident to the floor without injury. The ADON was asked if CNA #3 reported why they did not have a second person assisting. The ADON reported they thought the resident was in a hurry to get up so the aide did not wait for assist. The ADON reported there was plenty of staff available the day of the incident and there was no reason the aide could not get assistance with transferring the resident.
On 05/29/25 at 9:44 a.m., CNA #3 was interviewed by phone. CNA #3 reported on the day of the incident, Resident #3 wanted to get up for a smoke break and was in a hurry. CNA #3 reported they knew they should have gotten a second person to assist with the lift but did not take the time to get someone to help.
Oct 2024
5 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
On 10/03/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #38, who had been assessed to require supervision and a smoking apron whe...
Read full inspector narrative →
On 10/03/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #38, who had been assessed to require supervision and a smoking apron when smoking, was provided adequate supervision.
A care plan intervention, updated 01/31/24, documented Resident #38 required staff supervision with smoking and the use of a smoking apron.
A smoking assessment, dated 02/15/24, documented Resident #38 was safe for smoking with supervision and use of a smoking apron.
An incident report, dated 04/19/24, documented an unwitnessed incident. The report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. The incident report documented two small burns to the left side of the resident's face and under their left ear.
A smoking assessment, dated 09/08/24, read in part, Safe for smoking with one-on-one assist and a smoking apron.
On 10/03/24 at 12:41 p.m., Resident #38 was observed smoking without supervision and without a smoking apron. Cigarette ashes were observed on the resident's right thigh.
On 10/03/24 at 12:55 p.m., the AIT was observed to bring Resident #38 two cigarettes and provided assistance with lighting one of the cigarettes.
On 10/03/24 at 12:57 p.m., Resident #38 was observed smoking without a smoking apron. The AIT was observed providing water to other residents in the smoking area.
On 10/03/24 at 1:00 p.m., the AIT reported not being aware if Resident #38 required a smoking apron and would have to check.
On 10/04/24 at 1:25 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.
On 10/04/24 at 1:35 p.m., the administrator was notified of the IJ situation.
On 10/07/24 at 3:29 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented:
The facility asserts that the likelihood of serious harm no longer exists as of 10/04/24, at 4:30 p.m.
Issue Cited:
Resident #38 had smoking assessments, dated 01/31/24 and 02/15/24, and was found to be unsafe to smoke unsupervised and required smoking interventions. Care plan interventions, dated 01/31/24 and last reviewed 07/23/24, documented resident #38 required staff supervision and the use of a smoking apron. An incident report, dated 04/19/24, documented an unwitnessed smoking incident for resident #38 where he caught his beard on fire lighting his cigarette. The incident resulted in two small burns to left side of face and under left ear. A smoking assessment, dated 09/08/24, found resident to be unsafe for smoking without one-on-one assist, supervision and a smoking apron. Staff interview reported knowledge of resident needing to be supervised with smoking but not aware if a smoking apron was required. On 10/03/24 at 12:41 p.m., resident #38 was observed smoking in the designated smoking area unsupervised and without a smoking apron in place.
Identification of Residents Affected or Likely to be Affected: ( Completion Date 10/03/24.)
a.
Resident #38 reside in the building at time of the survey
b.
Resident #4 [name withheld]
c.
Resident #33 [name withheld]
d.
Resident #54 [name withheld]
e.
Resident #30 [name withheld]
Actions to Prevent Occurrence Recurrence:
1.
MDS conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status. 10/04/24.
2.
Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status. 10/04/24.
3.
Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status. 10/04/24.
4.
The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision. 10/03/24.
5.
The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers. 10/03/24.
6.
The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status. 10/03/24.
7.
The Administrator attended a resident meeting to review the smoking policy with the residents. 10/04/24.
8.
The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials. 10/03/24.
9.
The DON and Administrator conducted a smoking in-service for all employees, which was completed on 10/04/24. Ongoing education will be provided to new staff and as needed. Conduct telephonic in-service with staff who are currently out with follow up ongoing education prior to working their assigned shift.
10.
The Administrator conducted QAPI to discuss the smoking policy and procedure, completed on 10/03/24.
11.
Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers. 10/03/24.
12.
The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions. 10/04/24.
13.
Admissions and Social Service will review the smoking times and policy with each new admission. 10/04/24.
The IJ was lifted, effective 10/07/24 at 4:39 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained at an isolated with a potential harm.
Based on observation, record review, and interview, the facility failed to ensure adequate supervison was provided and a smoking apron was in place while smoking for one (#38) of three sampled residents reviewed for smoking safety.
The administrator identified 78 residents resided in the facility.
Findings:
An undated resident smoking policy, read in part, All safe smoking measures will be documented on each resident's care plan .Supervision will be provided as indicated on each resident's care plan .Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff or designee .
Resident #38 had diagnoses which included hemiplegia, seizure disorder and cerebral infraction.
A smoking assessment, dated 01/31/24, read in part, Residents need for adaptive equipment: smoking apron and supervision.
A smoking assessment, dated 02/15/24, read in part, Resident reassessed for smoking .Found to be safe to smoke with supervision and smoking vest .Charge nurse and staff made aware that the resident would need to be monitored while smoking and that the smoker's apron would need to be utilized.
A facility incident report, dated 04/19/24, documented an unwitnessed smoking injury. The incident report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. The incident report documented two small burns to the left side of the resident's face and under their left ear. The incident report, read in part, Area to left side of face cleansed with wound cleaner, pat dry, silvasorb applied, physician notified, resident agreed to allow staff to shave today, and two small one mm areas noted below left ear.
A smoking assessment, dated 04/24/24, read in part, Resident needs supervision when smoking and beard needs to be kept short .Resident unable to light cigarette safely and supervision required to ensure lit cigarette does not make contact with beard, hair, skin, and clothing.
A comprehensive assessment, dated 07/18/24, documented Resident #38 was dependent on staff for most activities of daily living and dependent on staff to ambulate with a wheelchair. The comprehensive assessment documented the resident was unable to complete the brief interview for mental status.
A care plan, last reviewed 07/23/24, read in part,
I require staff supervision/adaptations when using tobacco products, revised 01/31/24.
*Staff will complete a smoking assessment to ensure my safety quarterly, revised 01/31/24.
*I require assistance with lighting tobacco products only, initiated 10/29/21.
*I require the community to keep all tobacco and fire starting materials for, initiated 10/29/21.
*I require the use of an Adaptive Device: Smokers Apron, initiated 01/31/24.
*My smoking supplies are stored at the nurse's station, initiated 10/29/21.
A smoking assessment, dated 09/08/24, read in part, Safe to smoke with supervision, beard must be kept short, needs one-on-one assist and a smoking apron.
On 10/03/24 at 11:30 a.m., CNA #5 reported not being aware which residents required supervision with smoking. The CNA reported if a resident was required to be supervised, and an employee was available, they went out with the resident to smoke.
On 10/03/24 at 12:36 p.m., Resident #38 was observed sitting in their wheelchair by the smoking area door in the common area with an unlit cigarette in their mouth waiting to go outside.
On 10/03/24 at 12:41 p.m., Resident #38 was observed outside in the smoking area smoking. They were observed leaned over to the right in their wheelchair. There was no staff present in the smoking area and the resident did not have a smoking apron on. The resident was observed to have cigarette ashes on their right thigh and the cigarette was very short. The resident was observed dozing off to sleep while smoking.
On 10/03/24 at 12:50 p.m., Resident #38 was observed in the smoking area and no longer smoking. The resident's head was down and sleeping. The resident reported they were okay.
On 10/03/24 at 12:55 p.m., the AIT was observed to bring Resident #38 two cigarettes and provided assistance with lighting one of the cigarettes.
On 10/03/24 at 12:57 p.m., Resident #38 was observed smoking without a smoking apron. The AIT was observed providing water to other residents in the smoking area.
On 10/03/24 at 1:00 p.m., the AIT reported not being aware if Resident #38 required a smoking apron and would have to check.
On 10/03/24 2:22 p.m., CMA #2 reported cigarettes were kept on the medication cart. The CMA reported supervised smokers got a cigarette if they had someone to go out and smoke with them. The CMA reported they were not aware if Resident #38 required a smoking apron and was not aware where the smoking aprons were kept.
On 10/03/24 2:22 p.m., CMA #3 reported they went out with supervised smokers when they were working the floor. They reported they were not sure which smokers needed an apron. The CMA stated they thought Resident #38 required an apron due to just visualizing the resident outside smoking with a smoking apron on.
On 10/03/24 at 2:28 p.m., CNA #2 reported no smoking aprons had been used for smokers and was unaware where the smoking aprons were stored.
On 10/03/24 at 2:36 p.m., CNA #3 reported working on both sides of the facility. They reported Resident #38 required supervision with smoking due to leaning over to the side in their wheelchair, but not a smoking apron.
On 10/03/24 at 3:40 p.m. the administrator and AIT reported all staff should be aware who required smoking supervision and a smoking apron. The AIT reported three residents required supervision with smoking and a smoking apron. The administrator reported a new smoking policy was initiated, on 09/01/24 from corporate, and all staff had been in-serviced on the new policy. The AIT reported Resident #38 required a smoking apron and required supervision for smoking.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure an allegation of neglect was reported to the State Agency (OSDH) for one (#38) of one sampled resident reviewed for abuse.
The admi...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure an allegation of neglect was reported to the State Agency (OSDH) for one (#38) of one sampled resident reviewed for abuse.
The administrator identified 78 residents resided in the facility.
Findings:
Resident #38 had diagnoses which included hemiplegia.
A comprehensive assessment, dated 07/18/24, documented Resident #38's cognition was impaired and was dependent on staff to complete activities of daily living.
An incident report form ODH Form 283, dated 09/03/24, documented an allegation of neglect involving Resident #38. The incident report documented notifications made to the following: physician, family, local law enforcement, and nurse aide registry. The incident report documented no proof of the fax transmission.
On 10/03/24 at 9:37 a.m., the OSDH complaint department confirmed no incident reports had been received from the facility since 06/18/24.
On 10/03/24 at 10:00 a.m., the administrator provided an email confirmation submitted to the OSDH on 09/09/24 at 12:57 p.m. The administrator reported the email confirmation documented no proof the fax transmission was received by OSDH.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure advance directive acknowledgement forms were completed for t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure advance directive acknowledgement forms were completed for two (#10 and #24) of 18 sampled residents reviewed for advance directives.
Findings:
The administrator identified 78 residents resided in the facility.
The Advance Directives policy, dated December 2016, read in part, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive.
1. Resident #10 was admitted to the facility on [DATE] with a re-entry date of 09/15/24.
A physician order, dated 06/15/23, documented full code.
Full code was marked in the electronic record. No acknowledgement form for an advance directive was in the clinical record or electronic record.
2. Resident #24 was admitted to the facility on [DATE].
A physician order, dated 05/29/24, documented full code.
Full code was marked in the electronic record. No acknowledgement form for an advance directive was in the clinical record or electronic record.
On 10/01/24 at 3:15 p.m., the administrator was asked the reason the advance directive acknowledgements were completed for Residents #10 and Resident #24 during the current survey. They reported the acknowledgement forms were part of the admission packet, but at this time the forms were not being completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a Level II PASARR evaluation for three (#9, 38, and #60) of three sampled residents reviewed for PASARRs.
The administrator identified 78 residents resided in the facility.
Findings:
An undated Resident Assessment - Coordination with PASARR Program policy, read in part, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .
1. Resident #9 was admitted to the facility on [DATE].
The Level I PASARR screen, dated 09/06/07, documented no mental illness.
On 11/20/14, the resident was diagnosed with bipolar disorder.
On 12/18/29, the resident was diagnosed with major depressive disorder and schizophrenia.
2. Resident #38 was admitted to the facility on [DATE].
The Level I PASARR screen, dated 07/24/19, documented no mental illness.
On 06/06/20, the resident was diagnosed with major depressive disorder.
On 09/06/20, the resident was diagnosed with mood disorder.
3. Resident #60 was admitted to the facility on [DATE].
The Level I PASARR screen, dated 10/19/22, documented no mental illness.
On 11/21/22, the resident was diagnosed with schizoaffective disorder.
On 11/22/22, the resident was diagnosed with mood disorder.
On 10/02/24 at 3:19 p.m., the MDS coordinator reported not being aware if a residents new diagnosis of mental illness, not documented on the Level I PASARR screening at admission, had to be reported to the OHCA to evaluate the need for Level II services. They reported no PASARR policy had been received to follow for completing PASARR screenings. They reported they had only reported new mental illness if a resident had an inpatient mental hospital stay.
On 10/03/24 at 11:28 a.m., the MDS coordinator agreed, after reading over the facility's PASARR policy Resident #9, #38, and #60's new diagnoses of mental illness should have been reported to the OHCA when they were newly evident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure:
a. enhanced barrier precautions were implemented for two (#69 and #78) of three sampled residents observed during wou...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to ensure:
a. enhanced barrier precautions were implemented for two (#69 and #78) of three sampled residents observed during wound care;
b. enhanced barrier precautions were implemented for one (#69) of one sampled resident observed during Foley catheter care; and
c. contact precautions were implemented for one (#49) of one sampled resident observed for transmission-based precautions.
The ADON #2 identified one resident required TBP. The regional consultant identified 19 residents required enhanced barrier precautions. The administrator identified 78 residents resided in the facility.
Findings:
An Enhanced Barrier Precautions policy, dated 04/01/24, read in part,
*It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms.
*An order for enhanced barrier precautions will be obtained for wounds and/or indwelling medical devices.
*Make gowns and gloves available near or outside the resident's room.
*Face protection may also be needed if performing activity with risk of splash or spray.
*PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.
An undated isolation policy titled Contact Precautions, read in part,
*Implement contact precautions for residents known or suspected to be infection with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment
*Wear gloves when entering the room.
*Wear a disposable gown upon entering the contract precautions room.
*The facility will implement a system to alert staff to the type of precautions resident requires.
*The facility will also ensure that the resident's care plan and care specialist communication system indicates the type of precautions implemented for the resident.
1. Resident #78 had diagnoses which included diabetes mellitus, lung cancer, and dementia.
A comprehensive assessment, dated 9/13/24, documented Resident #78's cognition was severely impaired and required extensive assistance with activities of daily living.
A physician's order, dated 09/18/24, read in part, Cleanse right heel with wound cleanser, pat dry, apply leptospermum honey daily x 23 days .Float/off load heels as ordered .Left side of neck cleanse with wound cleanser, apply leptospermum honey, apply alginate calcium, cover with border gauze daily x 23 days .
A physician's order, dated 09/20/24, read in part, Cleanse sacrum wound with wound cleanser, pat dry, apply alginate calcium, apply island gauze cover with boarder dressing daily x 30 days.
On 09/30/24 at 11:25 a.m., the wound care nurse and wound physician removed the resident's wound dressing to coccyx, right heel, and left side of their neck. They were observed to wear gloves. There was no gowns donned for enhanced barrier precautions. The resident's room was observed to have no enhanced barrier precaution signage in place or PPE supplies outside of the room.
A care plan, dated 10/01/24, read in part, I have actual impairment to skin integrity of the neck related to infection of abscessed area to neck due to my cancer.
A care plan, dated 10/04/24, read in part, I am on enhanced barrier precautions related to skin openings, abscesses due to my cancer .Apply appropriate PPE during all high-contact resident care activities .Notify all staff of enhanced barrier precautions.
2. Resident #69 had diagnoses which included malignant neoplasm of connective and soft tissue and local infection of the skin and subcutaneous tissue.
A comprehensive assessment, dated 06/21/24, documented Resident #69's cognition was moderately impaired and dependent on staff for most activities of daily living.
A physician's order, dated 06/19/24, read in part, Foley catheter care every shift and as needed.
A physician's order, dated 09/24/24, read in part, Cleanse right anterior chest with wound cleanser, apply alginate rope with silver, apply collagen powder, cover with gauze island with boarder dressing daily x 30 days.
On 10/02/24 at 9:45 a.m., Resident #69's room had no enhanced barrier precautions signage or PPE supply available outside of the room.
On 10/02/24 at 9:49 a.m, ADON #1 provided wound care to the right side of Resident #69's chest. The ADON wore gloves to perform wound care, but no other PPE was donned related to enhanced barrier precautions.
On 10/02/24 at 2:09 p.m., CNA #3 donned a gown and gloves to empty Resident #69's Foley catheter bag. The CNA reported they did not like them to wear gowns to empty the Foley catheter bags, but they had started using them because it is messy. The resident's room was observed to have an enhanced barrier precautions signage on the door at this time.
A care plan, dated 10/04/24, read in part, I am on enhanced barrier precautions related to nonhealing surgical incision and indwelling catheter.
3. Resident #49 had diagnoses which included diabetes mellitus.
A comprehensive assessment, dated 09/01/24, documented Resident #49's cognition was moderately impaired and required substantial/maximal assistance with activities of daily living.
A physician's order, dated 09/30/24, read in part, Initiate contact isolation precautions for MRSA in the would of the toe .Gentamicin sulfate external ointment 0.1% apply to left great toe topically one time a day for wound infection x 10 days.
A care plan, dated 10/01/24, read in part, I have a diabetic ulcer of the left great toe related to diabetes .I do have MRSA to my toe, new orders and antibiotics obtained following results of wound culture .Contact isolation initiated.
On 10/02/24 at 12:34 p.m., Resident #49 was observed setting up in the recliner in their room with their feet elevated. The resident's wound to the left great toe was observed with no dressing in place. The resident reported the dressing was removed before their shower. The wound care nurse provided wound care to left great toe wearing gloves, no other PPE was used. The wound care nurse reported the resident's wound culture came back as a staph infection and they were treating with gentamycin ointment (antibiotic) for 10 days. The wound care nurse disposed of used wound care supplies in a clear plastic bag, then removed from the clear plastic bag from the room and placed the bag in the side trash can of the treatment cart.
On 10/02/24 at 2:34 p.m., ADON#2 reported not being aware of any resident having MRSA in a wound or on contact precautions. They reported signage for isolation, biohazard bags in the room, and PPE outside side the residents door should be in place for a resident on transmission based/contact . The ADON reported the wound care nurse/infection preventionist and charge nurse were responsible to ensure staff were aware of residents on isolation and putting out the PPE supplies and isolation signage. The ADON reported enhanced barrier precaution signage should not be used if a resident was on isolation precautions. They reported contact precautions for Resident #49 should have been put into place when the order was received.
On 10/02/24 at 3:00 p.m., ADON #2 reported Resident #49 should have had contact precautions in place, but staff had failed to do so. They reported residents with a Foley catheter and open wounds should have enhanced barrier precautions used by staff for catheter care and wound care. The ADON was not aware the reason staff were not following enhanced barrier precautions or the reason signage was not in place.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary, to include a recapitulation of the re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary, to include a recapitulation of the resident's stay, for two (#4 and #5) of two residents reviewed for discharge.
The administrator reported a census of 78 residents.
Findings:
A Discharging the Resident policy, dated December 2016, documented in part, .The resident should be consulted about the discharge .ensure that resident and/or responsible party receive teaching and discharge instructions .ensure that a transfer summary is completed .assess and document resident's condition at discharge .
1. Resident #4 was admitted to the facility on [DATE] and discharged on 05/04/24.
A physician order for resident #4, dated 05/03/24, documented to discharge the resident home on [DATE] with medications and discharge instructions.
An MDS discharge assessment for resident #4, dated 05/04/24, documented the resident was cognitively intact. The assessment documented the discharge was planned.
A discharge summary was not completed for resident #4.
2. Resident #5 was admitted to the facility on [DATE] and discharged on 09/08/24.
An MDS assessment, dated 07/03/24, documented resident #5 was cognitively impaired with memory problems.
Progress notes for resident #5, dated 09/08/24, documented the resident was discharged to another long term care facility. The progress notes documented the resident was being monitored for wandering behaviors.
A discharge summary was not completed for resident #5.
On 09/11/24 at 2:35 p.m., the DON reported discharge summaries could not be located but should have been completed for resident #4 and #5.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#5) of one resident reviewed for elopement.
The DON reported three residents who exhibit...
Read full inspector narrative →
Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#5) of one resident reviewed for elopement.
The DON reported three residents who exhibited exit-seeking behaviors and no incidents of elopement.
Findings:
An Elopements policy, dated December 2017, documented in part, .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .Examine the resident for injuries .Document the event in the resident's medical record .
Resident #5 was admitted with diagnoses which included hemiplegia/hemiparesis, hypertension, aphasia, dysphagia, muscle weakness, and a history of transient ischemic attack.
An MDS assessment for resident #5, dated 07/03/24, documented the resident was cognitively impaired and had memory problems. The assessment documented the resident ambulated independently.
A care plan for resident #5, dated 07/15/24, documented the resident was an elopement risk due to wandering behaviors. Interventions included assessment, distraction, and identification of patterns related to wandering.
On 09/06/24 at 5:10 p.m., the ADON reported they were not aware of any residents who had eloped. The ADON reported the facility had a couple of residents who were allowed to check themselves out of the facility and go into the community on their own.
On 09/10/24 at 10:50 a.m., CMA #1 and #2, and CNA #1, reported they were not aware of any resident elopements. The staff reported there were certain residents who were allowed to check themselves out of the facility and go into the community.
On 09/10/24 at 3:45 p.m., a resident who requested to remain anonymous reported they had heard about a resident getting out of the facility and going near the street. The resident gave a first name of the resident in question but did not know a last name. The resident stated they did not witness the incident and did not know the outcome.
On 09/10/24 at 4:10 p.m., the surveyor reviewed the resident roster and there was not a resident listed with the first name provided by the anonymous resident.
On 09/11/24 at 10:05 a.m., LPN #1 was interviewed regarding any incidents of resident elopement. The LPN reported there was a previous resident, resident #5, who had wandering behaviors but had never eloped on day shift. The LPN reported the resident had been discharged to another long term care facility.
On 09/11/24 at 10:15 a.m., the closed medical record for resident #5 was reviewed and documented the resident was discharged on 09/08/24 to another long term care facility. The nurse notes contained no documentation related to an elopement incident. Nurse notes documented the resident was being monitored for wandering behaviors.
On 09/11/24 at 10:26 a.m., the corporate RN reported there was not an incident report for resident #5 related to an elopement incident.
On 09/11/24 at 12:15 p.m., CNA #1 reported they had heard about resident #5 getting out of the facility but stated they did not witness it and they were not working at the time of the incident.
On 09/11/24 at 1:35 p.m., LPN #2 reported they worked at the facility the evening of 09/02/24 when they received a phone call at the nurse's station by an anonymous caller. The caller reported they thought one of the facility's residents was out of the building near the street. The LPN #2 stated by the time they got to the door, an unidentified staff member was walking in with resident #5 and the resident was unharmed. The LPN stated she thought the nurse she was training under was going to report the incident to the DON.
On 09/11/24 at 2:20 p.m., CNA #2 reported they were working the evening of 09/02/24 but had gone on break and wasn't aware of the incident with resident #5 until they got back from break. The CNA stated resident #5 was known to wander around the facility independently but they were not aware of the resident ever trying to leave the facility. The CNA #2 stated they talked with the resident that evening, the resident was unharmed, and staff continued to monitor the resident for wandering behaviors.
On 09/11/24 at 2:35 p.m., the DON reported they had been notified of resident #5 going out of the door toward the laundry room but stated the resident was never out of sight. The DON stated since the resident was never out of sight, they did not complete an incident report. The DON stated the door leading to the laundry room would not give the resident access to the street, and they were never informed of an incident when the resident got near the street. The DON reported the facility had been looking for more appropriate placement for resident #5 due to the resident's wandering behaviors, and the resident had been discharged on 09/08/24.
Aug 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a resident assessment as required for one (#76) of 22 resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a resident assessment as required for one (#76) of 22 resident assessments reviewed for timely transmission.
The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.
Findings:
Resident #76 was admitted on [DATE] and an MDS admission assessment was completed on 03/14/23.
A progress note, dated 04/18/23, documented the resident was discharged on this date. An MDS discharge assessment, returned not anticipated, was not completed for the discharged resident.
On 08/08/23 at 1:47 p.m., the former DON reviewed the assessments and reported a corporate staff member was completing resident assessments remotely. They reported a discharge assessment had not been completed as required and was greater than 120 days past due.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop a person-centered care plan for a resident who required respiratory treatments for one (#31) and failed to complete smoking safety ...
Read full inspector narrative →
Based on record review and interview, the facility failed to develop a person-centered care plan for a resident who required respiratory treatments for one (#31) and failed to complete smoking safety assessments quarterly for one (#42) of 19 sampled residents whose care plans were reviewed.
The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility and the DON identified 22 residents who required smoking safety assessments.
Findings:
1. A Care Planning - Interdisciplinary Team policy, dated September 2013, read in part, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team .
Resident #31 was admitted with diagnoses which included dysphagia, hypertension, and a history of pneumonia and sepsis.
Resident #31's care plan, dated 01/11/23, contained no documentation related to the resident's respiratory status.
An admission MDS assessment, dated 01/12/23, documented the resident was cognitively impaired. The assessment documented the resident had a major infection with pneumonia and sepsis. The assessment did not document the resident received respiratory therapy.
A progress note, dated 01/20/23 at 5:04 p.m., documented the resident received an Albuterol nebulizer treatment, ordered to be given every six hours as needed for shortness of breath or wheezing.
A progress note, dated 02/14/23 at 8:16 p.m., documented the resident was found to have audible rhonchi, a breathing treatment was administered, and a chest x-ray was ordered.
A nurse note, dated 02/16/23 at 9:24 a.m., documented administration of Albuterol Sulfate nebulizer treatment, ordered as needed every six hours for shortness of breath. The note documented the resident had audible wheezing and shortness of breath.
A nurse note, dated 03/28/23 at 2:48 p.m., documented the resident was wheezing. The note documented the physician was notified and orders received for a chest x-ray and routine breathing treatments.
A nurse note, dated 03/30/23 at 3:24 p.m., read in part, .X-ray findings-right perihilar infiltrate .notified new order for Levaquin 750 mg Q Day x 7 days .
An MDS quarterly assessment, dated 04/14/23, did not document the resident received respiratory therapy.
Resident #31's care plan, updated 08/04/23, was provided by RN #1. The care plan documented the resident had a self-care deficit related to activity intolerance. The care plan documented the resident received tube feedings related to dysphagia. The care plan did not include any documentation related to the resident's respiratory status.
On 08/08/23 at 8:55 a.m., RN #1 was interviewed regarding the resident's history of pneumonia and sepsis. The RN reviewed the MDS assessment and noted the assessment documented major infection with pneumonia and sepsis, but did not document the resident received respiratory therapy. The RN reviewed the resident's care plan and reported the care plan should have included the resident's respiratory status and the need for respiratory treatments.
2. A facility Smoking Policy, undated, read in part, .all residents that smoke will have a smoking evaluation completed and updated as needed .
A Smoking Safety Evaluation for Resident #42, dated 07/16/21, documented the resident was independent with smoking.
Resident #42's clinical record did not contain any other smoking evaluations.
A care plan for resident #42, dated 07/26/23, read in part, I am resistive to care (refusing to give smoking materials to staff) .Staff will complete a smoking assessment to ensure my safety quarterly .
On 08/07/23 at 2:53 p.m., Resident #42 was observed smoking outside in the courtyard with other residents.
On 08/08/23 at 3:09 p.m., the DON reviewed the clinical records and reported smoking safety assessments had not been completed and/or updated as required.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a process in place, to ensure medications were administered as...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a process in place, to ensure medications were administered as ordered, for one (#85) of six sampled residents reviewed for medication administration.
The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.
Findings:
A facility Subcutaneous Injections policy, dated March 2011, documented in part, Verify that there is a physician's medication order for this procedure .Review the resident's care plan to assess for any special needs of the resident .Follow documentation guidelines in the procedure entitled Documentation of Medication Administration .Report other information in accordance with facility policy and professional standards of practice .
Resident #85 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, embolism, and thrombosis.
Resident #85's care plan, dated 06/21/23, documented the resident received anticoagulant therapy related to atrial fibrillation, CVA, DVT, and valve replacement. The care plan documented to administer medications as ordered, at the same time on the days ordered.
The resident's MDS admission assessment, dated 06/23/23, documented the resident received anticoagulant medication seven of seven days previous.
The June 2023 TAR, documented an order for Enoxaparin Sodium Solution, 80 mg/0.8 ml, inject 80 mg subcutaneously every 12 hours for prevention of blood clotting. The order had a start date of 06/17/23. The TAR documented the medication was not administered on 06/17/23, 06/18/23, or 06/19/23. The TAR documented the first dose was administered at 8:00 a.m. on 06/20/23, and the resident was discharged on 06/23/23 after receiving one dose that day. The TAR documented the resident received a total of seven doses.
On 08/02/23 at 3:51 p.m., LPN #1 was interviewed regarding the TAR for resident #85. The TAR documented the first five doses of Enoxaparin were not administered on 6/17/23, 6/18/23, or 6/19/23. The TAR documented OT where the medication was not given. The LPN reported OT was for other and the system would prompt the nurse or CMA to enter a progress note to explain why the medication was not given. The LPN reviewed the progress notes and determined the medication was initially entered on the MAR instead of the TAR. Because the medication was entered on the MAR, and CMAs did not administer injections, the CMAs had entered on the progress notes, nurse will give. LPN #1 stated if she had a resident on Lovenox [Enoxaparin], she would know to look in the treatment cart for the medication and if she didn't find it there, she would check the medication room or ask other staff. The LPN stated the progress notes were confusing because the CMAs were documenting nurse will give but there was no follow-up to indicate a nurse had seen the note or responded in any way.
On 08/02/23 at 3:58 p.m., the DON reported she had recognized there needed to be an improvement in shift report and communication between the CMAs and nurses in regard to any questions about medications.
On 08/03/23 at 9:04 a.m., RN #1 reported she had checked to see exactly how many doses of Enoxaparin were delivered to the facility, how many doses were administered, and how many were left when the resident discharged on 06/23/23. The RN reported 10 doses were delivered and three doses remained in the facility, which indicated the resident had received a total of seven doses.
On 08/03/23 at 10:04 a.m., RN #1 reported the previous ADON had entered the order for the Enoxaparin injections on the MAR instead of the TAR. CMA #1 recognized the medication had been entered on the MAR instead of the TAR and notified the ADON. CMA #2 was also involved in entering progress notes related to the Enoxaparin but all of these staff members were no longer employed at the facility. RN #1 reported the medication was in-house and stated it was delivered on 06/16/23. The RN provided an invoice which documented 10 doses of Enoxaparin were delivered.
On 08/03/23 at 4:04 p.m., the resident's physician was interviewed regarding Resident #85 missing five doses of the anticoagulant, Enoxaparin. The physician reported the resident was on another anticoagulant at the same time and was being monitored. The physician reported the missed doses of Enoxaparin did not cause a negative outcome to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure required staff in-service training was provided to address d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure required staff in-service training was provided to address dementia management, pain recognition, first aid procedures, CPR, and the Heimlich maneuver.
The Resident Census and Conditions of Residents form, dated [DATE], documented 92 residents resided in the facility.
Findings:
On [DATE] at 4:15 p.m., facility in-service and education records were reviewed. The records contained no documentation of staff training for required dementia management, pain recognition, first aid procedures, CPR, or Heimlich training.
On [DATE] at 4:51 p.m., RN #1 reported they were unable to locate any documentation related to the required in-services being provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to notify the physician, per physician orders, for systolic blood pressure readings out of parameters for one (#13) of five residents reviewed...
Read full inspector narrative →
Based on record review and interview, the facility failed to notify the physician, per physician orders, for systolic blood pressure readings out of parameters for one (#13) of five residents reviewed for physician orders.
The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.
Findings:
A facility policy and procedure, Change in a Resident's Condition or Status, read in part, .specific instruction to notify the Physician of changes in the resident's condition .
Resident #13 was admitted with diagnoses which included hypertension.
A physician order, dated 12/08/22, documented to administer Norvasc 5 mg [a blood pressure medication], one tablet by mouth daily, and to call the physician if the systolic blood pressure was above 180.
Medication administration records for resident #13 documented the following blood pressure readings:
05/15/23 - B/P 190/90
05/23/23 - B/P 193/86
06/16/23 - B/P 197/96
06/27/23 - B/P 191/88
07/07/23 - B/P 188/82
07/16/23 - B/P 193/65
Resident #13's clinical record did not document the physician was notified of the systolic blood pressure readings.
On 08/07/23 at 3:29 p.m., RN #1 reviewed the clinical record and reported they were unable to find any documentation to indicate the physician had been notified of the above findings. The RN reported the physician should have been notified, per physician orders, each time the B/P readings were out of range.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to complete performance reviews for CNAs as required annually.
The DON reported 15 CNAs had been employed and worked in the facility for over ...
Read full inspector narrative →
Based on record review and interview, the facility failed to complete performance reviews for CNAs as required annually.
The DON reported 15 CNAs had been employed and worked in the facility for over one year.
Findings:
A review of facility records was conducted and did not document an annual skills review had been completed for CNAs who had worked in the facility for at least one year.
On 08/08/23 at 4:51 p.m., RN #1 reported performance reviews had not been completed and there was no documentation related to a review of CNA competencies.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility remained free of flies.
The Resident Census and Conditions o...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility remained free of flies.
The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility.
Findings:
A facility Pest Control policy, dated May 2008, documented in part, This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents .Maintenance services assist, when appropriate and necessary, in providing pest control services .
On 08/01/23 at 11:30 a.m., a tour of the facility was conducted. Numerous flies were observed throughout the building. Flies were observed in all hallways, at nurse stations, in resident rooms, in common areas, and in the dining room.
On 08/01/23 at 12:05 p.m., a tour of the facility kitchen was conducted and one fly was observed in the kitchen. Approximately six flies were observed in the main dining room.
On 08/02/23 at 9:31 a.m., Resident #34 was observed to be sitting at the nurse's station. Four flies were observed flying around the resident's face and head, landing on the resident's shoulders and hair. An unidentified nurse reported the flies had been especially bad lately and she thought they were worse at the nurse's station because of the door nearby leading out to the courtyard where residents smoked.
On 08/02/23 at 9:35 a.m., CNA #1 was asked if anything had been done about the flies and she stated someone had come out last week and sprayed, but nothing seemed to help. The CNA reported several residents who smoked went in and out of the doors to the courtyard throughout the day, and she felt this contributed to the fly problem.
On 08/02/23 at 11:02 a.m., multiple flies were observed around the medication cart, landing on residents and staff. LPN #2 was asked if she was aware of anything the facility was doing to help with the flies. The LPN reported she usually worked weekends but she had not observed any interventions. The LPN stated something needed to be done because the flies had been awful.
On 08/04/23 at 10:29 a.m., Resident #31 was observed lying in bed with the blanket pulled up over their face and four flies were observed to be hovering around the resident's head. The resident was asked if the flies were bothering them and they stated, yeah. Two staff members were observed in the hallway outside of the resident's room. The staff were asked to check on the resident and see if they could do anything to make the resident more comfortable.
On 08/07/23 at 3:03 p.m., Resident #31 was observed during care of their tube feeding site. The resident was observed to have a fly strip hanging from the ceiling and had a fan blowing toward their bed. There were no flies observed at that time. Staff was uncertain of when the fly strip and fan were placed in the resident's room.
On 08/08/23 at 10:04 a.m., LPN #3 was asked about the fly strip and fan in Resident #31's room, and asked if maintenance had done this to help with the flies. The LPN reported the resident's family had done this over the weekend. CNA #1 reported the resident's daughter had visited over the weekend, stated the flies were awful, so the daughter put the fly strip up herself and placed the fan in the resident's room to try and help with the fly situation.
On 08/08/23 at 10:47 a.m., pest control receipts were reviewed and documented monthly routine pest control. A detailed Products Summary, dated 07/13/23, documented the pest control company targeted crickets and flies. An invoice, dated 07/26/23, documented hallways were treated with Alpine Fly Bait.
Nov 2022
3 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, the facility failed to implement comprehensive care plan interventions for three (#9, #24, and #45) of five residents reviewed for the use of unneces...
Read full inspector narrative →
Based on record review, observation and interview, the facility failed to implement comprehensive care plan interventions for three (#9, #24, and #45) of five residents reviewed for the use of unnecessary meds.
The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility.
Findings:
1. Resident #9 had diagnoses which included anxiety, depression, and Schizophrenia.
The resident's Care Plan, dated 08/27/22, read in parts, .The resident uses antidepressant medication related to depression .Administer antidepressant medications as ordered by physician Monitor/document side effects and effectiveness every shift .The resident uses psychotropic medications related to schizophrenia .Administer psychotropic medications as ordered by physician .Monitor for side effects and effectiveness every shift .The resident has depression .Administer medications as ordered .Monitor/document for side effects and effectiveness .
The Quarterly MDS Assessment, dated 09/23/22, documented the resident's cognition was intact and no behaviors were exhibited. The assessment documented the resident received antipsychotic and antidepressant medication for seven of the seven previous look back days.
The resident's Treatment Administration Record, dated 11/01/22, documented the following psychotropic medications: Seroquel 25 mg three at bedtime, bupropion extended release 150 mg one every day, escitalopram oxalate 20 mg one every day, Depakote delayed release 250 mg one every day, and Depakote delayed release two at bedtime. The TAR documented no monitoring of the resident's side effects of taking psychotropic medication or the effectiveness of the medication had been conducted every shift.
2. Resident #24 had diagnoses which included major depressive disorder and anxiety disorder.
The resident's Care Plan, dated 09/08/22, read in parts, .Use of anti-anxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor/document side effects and effectiveness every shift .Use of psychotropic medications related to behavior management .Administer psychotropic medications as ordered by physician .Monitor for side effects and effectiveness every shift .Diagnoses of major depressive disorder .Administer medications per physician orders .Monitor for effectiveness and signs and symptoms of adverse reaction .
The resident's MDS Assessment, dated 10/17/22, documented moderately impaired cognition with no behaviors exhibited. The assessment documented antipsychotic and anti-anxiety medications had been administered for seven of the previous seven days.
The resident's Physician Orders, dated 11/01/22, documented psychotropic medication as follows: Risperdal 0.5 mg one at night and Ativan 0.5 mg one twice a day.
The resident's TAR, dated 11/01/22, documented no monitoring every shift for the effectiveness and side effects of psychotropic medication.
3. Resident #45 had diagnoses which included anxiety disorder, mood disorder, pseudobulbar affect, and shaken infant syndrome.
The resident's Quarterly MDS Assessment, dated 08/23/22, documented severely impaired cognition with verbal behaviors. The assessment documented the resident received anti-anxiety and antidepressant medication for seven of the previous seven days.
The resident's Care Plan, dated 08/27/22, read in parts, .Resident uses anti-anxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor for side effects and effectiveness every shift .Resident uses antidepressant medication related to pseudobulbar affect and mood disorder .Administer antidepressant medications as ordered by physician .Monitor/document side effects and effectiveness every shift .
The resident's Physician Orders, dated 11/01/22, documented the following psychotropic medications: Nuedexta 20-10 mg one twice a day, Klonopin 0.5 mg one at night, and mirtazapine 7.5 mg one at night.
The resident's Treatment Administration Record, dated 11/01/22, documented no monitoring had been conducted every shift related to the side effects and effectiveness of psychotropic medication.
On 11/17/22 at 2:17 p.m., the ADON reported the resident's side effects and effectiveness to psychotropic medications should be documented on the resident's treatment administration record. The ADON agreed the care plan had not been followed for resident #9, 24, and #45 related to monitoring the side effects and effectiveness of psychotropic medications every shift and documented on the resident's TAR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to ensure care plans were updated for two (#9, and #44) of 14 residents whose care plans were reviewed.
The Resident Census and...
Read full inspector narrative →
Based on record review, observation, and interview, the facility failed to ensure care plans were updated for two (#9, and #44) of 14 residents whose care plans were reviewed.
The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility.
Findings:
1. Resident #9 had diagnoses which included bilateral below knee amputation and mild cognitive impairment.
The resident's Smoking Safety Evaluation, dated 08/18/22, read in parts, .The resident cannot dispose of ash safely, without ash falling onto resident's clothes .Adaptive equipment needed includes smoking apron and supervision .Resident needs facility to store lighter and cigarettes .Plan of care is used to assure resident is safe while smoking .Safe to smoke with supervision per team decision .Rationale/Conditions: resident is unsafe to smoke alone, she must be supervised and wear a smoking apron.
The resident's Care Plan, revised 08/27/22, read in parts, .For my safety, I need to wear a fireproof apron when smoking .My smoking supplies are to be stored by the nurse .I cannot smoke unless I am supervised .I am able to safely use and maintain smoking materials(01/25/21) .
The resident's Quarterly MDS Assessment, dated 09/23/22, documented cognition intact and one staff physical assist with most activities of daily living.
On 11/17/22 at 9:52 a.m., resident #9 was up in her wheelchair by the nurse's station, transport staff member handed a pack of cigarettes to the resident which she put in side a small bag she carried. Resident observed to be able to self-propel in manual wheelchair around the facility and to go outside to smoke.
On 11/17/22 at 10:05 a.m., the resident was observed in the facility courtyard, smoking without supervision of staff, and not wearing a smoking apron.
On 11/17/22 at 2:08 p.m., the resident reported no longer being required to wear a smoking apron or be supervised while smoking. The resident reported being allowed to store cigarettes and lighter on self. The resident reported having smoking restrictions after surgery when staff had to assist her in a Geri chair around the facility. The resident reported since the use of a Geri chair was no longer needed, she is safe to smoke unsupervised, without a smoking apron, and can store her smoking supplies.
On 11/17/22 at 2:15 p.m., LPN #1 reported the resident was did not require supervison with smoking, since she no longer used the Geri chair.
On 11/17/22 at 2:16 p.m., the transportation driver reported the resident was allowed to smoke unsupervised and allowed to store own smoking supplies. The transportation driver reported getting cigarettes out of the nurse cart for the resident earlier that day.
On 11/17/22 02:17 p.m., the ADON reported resident #9 was no longer required to be supervised with smoking and no longer required a smoking apron. The ADON reported the resident was allowed to store her smoking supplies safely. The ADON reported the smoking precautions were put in place post-surgery when a Geri chair was used for the resident. The ADON reported the resident's care plan should have been revised to remove the smoking precautions.
2. Resident #44 quarterly assessment, dated 09/05/22, documented the resident had a mood disorder. It documented the resident was on an antipsychotic.
The resident's care plan, dated 11/19/21, read in parts, The resident uses antidepressant medication (olanzipine) .Administer antidepressant medications as ordered by physician .Olanizipine dosage was reduced on 11/19/21.
A physicians order, dated 11/19/21, read Olanzapine tablet give 2.5 mg by mouth one time a day related to unspecified mood [affective] disorder.
A physicians order, dated 07/21/22, read Olanzapine tablet give 5 mg by mouth one time a day related to unspecified mood [affective] disorder.
On 11/17/22 at 11:15 a.m., the corporate nurse reported olanzipine is not an antidepressant, it's an antipsychotic.
On 11/18/22 at 10:10 a.m., the ADON reported the care plan should have been updated to show it's an antipsychotic and the olanzipine had been increased.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to ensure the physician or facility staff acted upon pharmacist recommendations of findings identified during monthly medication...
Read full inspector narrative →
Based on record review, observation, and interview, the facility failed to ensure the physician or facility staff acted upon pharmacist recommendations of findings identified during monthly medication regimen reviews for four (#9, 24, 44, and #45) of five residents reviewed for unnecessary medications.
The Resident Census and Census of Conditions, dated 11/15/22, documented 78 residents resided in the facility.
Findings:
The facility's Medication Regimen Review policy, dated 01/01/18, read in parts, .The consultant pharmacist reviews the medication regimen of each resident at least monthly .The consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards .The consultant pharmacist identifies irregularities through a variety of sources of the resident .The consultant pharmacists documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for the prescriber and/or nursing review .Recommendations are acted upon and documented by the facility staff and/or the prescriber within 30 days .
1. Resident #9 had diagnoses which included anxiety disorder, depression, schizophrenia and hypertension.
The resident's Medication Regimen Review, dated 04/10/22, documented recommendation to discontinue the PRN order for nystatin powder due to non-use. The MRR documented no action taken from the physician.
The resident's Medication Regimen Review, dated 05/17/22, documented the resident was taking lisinopril and lorsartan which are duplication of therapy, consider to discontinue one of these orders. The MRR documented no action taken by the physician.
The resident's Medication Regimen Review, dated 05/17/22, documented a pharmacist recommendation to add an order to monitor behaviors and adverse effects of psychotropic medications. The MRR documented no action taken by the physician or facility staff.
The resident's Medication Regimen Review, dated 06/05/22, documented to consider a gradual dose reduction of antidepressant therapy, buproprion xl 150 mg daily to bupropion xl 75 mg daily. The MRR documented no action taken by the physician.
The resident's Medication Regimen Review, dated 07/23/22, documented to consider a trial dosage reduction of Depakote dr 250 mg every morning and 500 mg at night to Depakote dr 250 mg twice a day per CMS regulation. The MRR documented no action taken by the physician.
The resident's Medication Regimen Review, dated 07/23/33, documented quetiapine requires antipsychotic behavior and side effect monitoring, and bupropion and Lexapro requires antidepressant side effect monitoring. The MRR documented no action taken by the physician or facility staff.
The resident's Care Plan, dated 08/27/22, read in parts, .At risk for side effects related to psychotropic medication therapy .Resident uses antidepressant medication related to depression .The resident uses psychotropic medications related to schizophrenia .The resident has depression .The resident has hypertension .
The Quarterly MDS Assessment, dated 09/23/22, documented the resident's cognition intact and no behaviors exhibited. The assessment documented the resident received antipsychotic and antidepressant medication for seven of the seven previous days.
The resident's Physician Orders, dated 11/01/22 documented the following: Seroquel 25 mg three at bedtime, bupropion extended release150 mg one every day, escitalopram oxalate 20 mg one every day, Depakote delayed release 250 mg one every day, and Depakote 250 mg delayed release two at bedtime, lisinopril 10 mg two every day, metoprolol succinate extended release 25 mg one every day, Hydralazine Hcl 25 mg one very six hours as need for systolic blood pressure greater than 170, Nystatin powder applied to groin as needed, and no order was in place to monitor behaviors or side effects of psychotropic medication.
On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022.
2. Resident #24 had diagnoses which included major depressive disorder, and anxiety disorder.
The resident's Medication Regimen Review, dated 05/17/22, documented recommendation to add an order to monitor behaviors and adverse side effects of psychotropic medications. The MRR documented no action taken by the physician or facility staff.
The resident's Care Plan, dated 09/08/22, read in parts, .Use of anti-anxiety medications related to anxiety disorder .Use of psychotropic medications related to behavior management .Diagnoses of major depressive disorder .
The resident's MDS Assessment, dated 10/17/22, documented moderately impaired cognition with no behaviors exhibited. The assessment documented antipsychotic and anti-anxiety medications had been administered for seven of the previous seven days.
The resident's Physician Orders, dated 11/01/22, documented Risperdal 0.5 mg one at night, Ativan 0.5 mg one twice a day and no order to monitor behaviors and adverse effects of psychotropic medications.
On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022.
On 11/18/22 at 10:00 a.m., the ADON reported the task of ensuring MRRs are acted upon has been assigned to the DON.
3. Resident #44 had diagnoses which included mood disorder.
The resident's Quarterly MDS Assessment, dated 09/05/22, documented cognition moderately impaired and received an antipsychotic medication.
The resident's Care Plan, dated 11/19/21, read in parts, The resident uses antidepressant medication (olanzipine) .olanzipine doseage reduced on 11/19/21.
The resident's Medication Regimen Review, dated 09/16/22, documented a recommended trial dose reduction of olanzapine 5 mg given one time a day. The MRR documented no action was taken by physician.
The resident's Physician Orders, dated 11/01/22 documented olanzapine 5 mg one daily.
On 11/17/22 the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed to ensure the recommendations were acted upon for the time period of April 2022 to October 2022.
4. Resident #45 had diagnoses which included anxiety disorder, mood disorder, and pseudobulbar affect.
The resident's Medication Regimen Review, dated 05/17/22, documented the recommendation to add an order to monitor behaviors and adverse effects of antidepressant medications. The MRR documented no action taken by the physician or facility staff.
The resident's Quarterly MDS Assessment, dated 08/23/22, documented severely impaired cognition with verbal behaviors. The assessment documented the resident received anti-anxiety and antidepressant medication for seven of the previous seven days.
The resident's Care Plan, dated 08/27/22, read in parts, .Resident uses antianxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor for side effects and effectiveness every shift .Resident uses antidepressant medication related to pseudobulbar affect and mood disorder .Administer antidepressant medications as ordered by physician .Monitor/document side effects and effectiveness every shift .
The resident's Physician Orders, dated 11/01/22, documented the following psychotropic medications: Nuedexta 20-10 mg one twice a day, Klonopin 0.5 mg one at night, mirtazapine 7.5 mg one at night, and no order to monitor behaviors and adverse effects of antidepressant medications.
On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $40,541 in fines. Review inspection reports carefully.
- • 18 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $40,541 in fines. Higher than 94% of Oklahoma facilities, suggesting repeated compliance issues.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Willow Park Health's CMS Rating?
CMS assigns WILLOW PARK HEALTH CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oklahoma, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Willow Park Health Staffed?
CMS rates WILLOW PARK HEALTH CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Oklahoma average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Willow Park Health?
State health inspectors documented 18 deficiencies at WILLOW PARK HEALTH CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Willow Park Health?
WILLOW PARK HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SOUTHWEST LTC, a chain that manages multiple nursing homes. With 151 certified beds and approximately 75 residents (about 50% occupancy), it is a mid-sized facility located in LAWTON, Oklahoma.
How Does Willow Park Health Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, WILLOW PARK HEALTH CARE CENTER's overall rating (1 stars) is below the state average of 2.6, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Willow Park Health?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Willow Park Health Safe?
Based on CMS inspection data, WILLOW PARK HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Willow Park Health Stick Around?
Staff turnover at WILLOW PARK HEALTH CARE CENTER is high. At 61%, the facility is 15 percentage points above the Oklahoma average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Willow Park Health Ever Fined?
WILLOW PARK HEALTH CARE CENTER has been fined $40,541 across 1 penalty action. The Oklahoma average is $33,484. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Willow Park Health on Any Federal Watch List?
WILLOW PARK HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.