The Willow, an Inspirit Senior Living Community

A resident reported missing belongings, but the incident was not reported to the department within the required timeframe.

The home failed to follow prescriber orders when a resident was administered 23 units of insulin instead of the prescribed 34 units.

A resident's most recent medical evaluation was not completed at least annually.

Failure to implement procedures for safe medication storage and use, including unavailable PRN medications and discrepancies between glucometer readings and medication administration records.

Failure to follow prescriber's orders regarding insulin sliding scale administration based on blood glucose readings.

Medication administration records did not include the initials of the staff person who administered insulin at 12 P.M.

A computer on the medication cart was left unlocked and unattended, making resident private information accessible.

An incident report was not submitted to the Department regarding a medication error where a resident's daily medication was unavailable.

A resident's contract had not been signed by the resident at the time of inspection.

The licensing inspection summaries dated 10/24/24 and 3/7/24 were not posted in a conspicuous and public place.

The resident's support plan was not updated to include newly identified needs following a change in care level from C to E++.

A resident's most recent annual documented medical evaluation was completed on 4-22-23.

A resident's most recent annual support plan was completed on 4-26-23, exceeding the required revision timeline.

Three staff members administered medications without having successfully completed the Department-approved medications administration course.

The resident's support plan failed to document specific behaviors, such as removing hearing aids and toileting needs, and the home's plan to address them.

The facility did not have a resident's prescribed PRN medication on hand for administration.

A resident's insulin pen was not dated and initialed when it was opened for use.

Support plans for residents using bed enabler bars failed to document the specific need, intended use, and associated risks of the device.

A staff person made a disrespectful remark to a resident, causing the resident to become upset.

A large plastic canister containing sugar did not close properly due to a broken hinge.

Large kitchen trash container was uncovered and a medium trash container lacked a lid.

A cardboard box containing rotting bananas was found on a kitchen shelf, attracting fruit flies.

The large baking oven in the kitchen had a broken off turn knob.