The Medicare inspection conducted on 4/28/2021 revealed that facility staff failed to ensure that a resident who had expressed suicidal/homicidal ideation was properly assessed and monitored. They also failed to notify the resident’s physician. These oversights created an immediate jeopardy situation—a situation in which a nursing home’s noncompliance with certain requirements has the potential to cause serious harm, injury, impairment, or death to a resident.
During the 4/28/2021 Medicare inspection, it was observed that facility staff were not adhering to required precautions and monitoring practices when changing the dressing for a resident’s PICC line. This violated physician’s orders and safety precautions.
In addition to the above infractions, during the 4/28/2021 inspection, a conflict was discovered between a resident’s dialysis treatment schedule and the records. Documentation from January, February, March, and April indicated the resident had received treatment at times when they were actually not in the facility—meaning the treatment could not have taken place at these times. Though the conflict was reported, no measurable effort was made to rectify it.
Willow Terrace Nursing & Rehabilitation Center is located at One Penn Boulevard, Philadelphia, PA 19144.
