Willow Ridge Memory Care

The facility failed to administer medications as ordered for 2 of 5 sampled residents regarding medications used to treat breathing difficulties and hypertension. Specifically, medication administration did not align with the orders maintained in the residents' records.

The facility failed to administer medications as ordered for 2 of 5 sampled residents. Specifically, for Resident #4, there was no documentation of prescribed nebulizer treatments for COPD between 10/04/24 and 10/08/24, and subsequent entries cited missing equipment or pharmacy delays instead of administration.

The facility failed to provide necessary personal care assistance to 4 out of 5 sampled residents. Specifically, staff failed to provide adequate nail care, bathing, and skin assessments, as evidenced by a resident having overgrown, broken, and discolored fingernails and toenails.

The facility failed to ensure staff provided necessary personal care assistance to 4 out of 5 sampled residents. Specifically, staff failed to provide adequate nail care, bathing, and skin assessments, as evidenced by residents having overgrown, broken, or discolored nails and a lack of documented skin assessments.

The facility failed to maintain infection prevention and control policies consistent with CDC and NCDHHS guidelines. Specifically, the facility did not ensure that staff were properly utilizing necessary personal protective equipment (PPE) during the COVID-19 pandemic.

Based on observations and reviews, staff failed to wear N95 masks and eye protection during patient care encounters. Additionally, staff were not appropriately removing PPE and disposing of it in the trash before exiting COVID-19 positive rooms.

The facility failed to provide an orderly discharge for one resident who was transferred to a local hospital. Specifically, the facility was unable to meet the resident's psychiatric needs, yet failed to follow required discharge preparation and orientation protocols.

The facility failed to ensure medications were administered in accordance with orders from a licensed prescribing practitioner. Specifically, Resident #5 was administered melatonin for several weeks after the 7-day prescribed course had expired, and the facility was using 'house stock' over-the-counter melatonin because no pharmacy refills had been requested or received.

The facility failed to ensure staff responded immediately with appropriate care during a resident medical emergency. Specifically, during an incident where a resident became unresponsive, the staff members providing CPR were not currently CPR certified. Additionally, the facility's staffing schedule failed to properly identify or ensure the presence of CPR-certified personnel on duty.