Champions Healthcare at Willowbrook

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting. The facility failed to report an allegation made by Resident #1 of sexual abuse on 7/27/26 to the State Survey Agency within the 2-hour timeframe. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation for 2 of 5 (Resident #44 and Resident #35) residents reviewed for abuse. The facility failed to protect Resident #44 from being slapped in the chest by Resident #35, in the hallway near the dining room, on 04/13/2026The failure placed residents at risk of injuries and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 5 residents (Resident #66) reviewed for ADL care. The facility failed to ensure LVN R assisted Resident #66 off the bedpan in a timely manner on 4/20/26, causing physical and emotional pain to the resident. This failure could place the residents at risk of decreased feelings of self-worth and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 2 (1st floor kitchen) kitchens reviewed for food service safety. The kitchen staff failed to check temperatures before meal service to ensure food were held at safe temperatures in the 1st floor kitchen (main kitchen). This deficient practice could place residents at risk for foodborne illness due to unsafe temperatures.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #16) reviewed for pharmacy services. LVN E did not ensure the accurate administration of Novolog and Lantus insulins (a hormone to help regulate blood sugar levels of individuals who have diabetes) per manufacturer's instructions. LVN E did not prime the insulin pen (removing air bubbles from the needing) prior to administering to Resident #16 on 04/22/26. LVN E did not ensure the accurate administration of Novolog (a rapid acting insulin) and Lantus (a long acting insulin) per manufacturer's instructions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #42 and Resident #57) reviewed for storage of medications. The facility failed to keep Resident #42 and Resident #57's medications secured. The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, drug diversion, or ingestion of unprescribed medications to residents, staff, and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents medical records were accurate for 1 of 5 (CR #1) residents reviewed for medical records The facility failed to update CR #1's advance directive and care plan after receiving a completed DNR form from the physician and responsible party. This failure could cause a violation to the residents' right to self-determination.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #52, # 17 and #98) reviewed for infection control. MA D failed to sanitize the automated blood pressure cuff used between Residents #52, #17 and #98 when checking blood pressures during medication pass. This deficient practice could affect residents needing blood pressure checks and place them at risk of cross contamination and infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to assure the accurate dispensing, and administering of all drugs to meet the needs for 2 of 5 residents (CR#1 & CR# 2) reviewed for medication administration, in that: The facility failed to ensure that CR#1's and CR#2's received their medications as ordered by their physician. This failure could place residents at risk of been overmedicated or undermedicated and not getting the therapeutical effect of the medications to improve their quality of life. Record review of CR#1's admission record dated 3/17/2026 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air. 2) The facility failed to store food thickener items six inches off the floor and ensured it was not exposed to air. 3) The facility failed to maintain the proper temperature of the high heat sanitizing dish machine. The failures could have placed residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff reviewed for infection control. 1. CNA E failed to perform hand hygiene when passing lunch trays on the 100 hall. 2. The DM did not conduct hand hygiene before giving Resident #5 her lunch tray, hugged another resident, and went to another resident. The DM then went from one resident to another doing a fist bump and shaking hands in between handing out resident trays and did not conduct handwashing or hand hygiene. 3. CNA F did not sanitize her hands between residents' trays and touched her clothes twice. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #5) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #5's dignity on 10/28/2025 while dining when staff did not serve the resident her lunch tray at the same time as other residents at the same table. This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comfortable and safe temperatures were maintained between 71F - 81F for 20 out of 20 residents (#2, #5, #9, #15, #17, #19, #21, #23, #24, #31, #35, #42, #45, #47, #49, #53, #57, #77, #140, and #190) reviewed for a safe and comfortable environment. - The facility failed to have a working heating system that provided heat to all resident rooms and used portable space heaters that did not monitor and adjust to room temperature but instead put out fixed heat, leaving some residents cold and room temperatures below 71 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 100-hall ranged from 67.1 to 70.4 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 200 hall ranged from 64.6 to 70.2 degrees Fahrenheit. [...]

Inspectors wrote[NAME], Kymyaka Based on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (CR#1) reviewed for wound care. -The facility failed to obtain wound care orders for CR#1's sacral wound upon admission from 06/11/2024-06/17/2024, and failed to document that the orders were implemented once obtained from 06/17/2024-06/20/2024. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 of 3 residents (Resident #37, #14, #16) reviewed for activities. The facility failed to provide Residents #37, #16 and' #14 with activities designed to meet their interests and promote physical, mental, and psychosocial well-being. This failure could affect residents at the facility who require assistance to activities to decline in mental acuity due to lack of stimulation, boredom, and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for food storage sanitation in that: The facility failed to store raw meat properly in the refrigerator. This failure could place residents at risk for cross-contamination and food-borne illnesses. This failure could place all residents who received meals at the facility at risk for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #8, reviewed for care plans in that: -Resident #8's code status (full code) was not care planned. This failure could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, record review the facility failed to establish a system of records, receipts, and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and account for all controlled drugs for one resident (Resident #99) reviewed for disposition of drugs in a sample of 8 residents. It was determined the facility failed to provide pharmaceutical services that ensure the accurate administering of drugs for 1 of 2 medication rooms observed for medications stored and properly labeled. One of the medication rooms had 2 glucagon pens, used for injection, that were expired. A medication, Tramadol, did not have a narcotic record amount that matched the quantity on hand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of one wound care carts (Hall 100 nurse medication cart) reviewed for drug storage in that: -Wound Care cart on Hall 100 was left unlocked and unattended. LVN E left medications unsupervised that were assessable to residents. This failure could place residents who reside on Hall 100 who receive treatment from the wound care cart at risk for harm to unauthorized people and place the facility at risk for possible drug diversion.