Willow Brook Christian Home

Inspectors wroteBased on review of the Legionella plan, policy review and staff interview, the facility failed to ensure the Legionella plan parameters for temperature readings were followed and failed to ensure new interventions were initiated for documented temperatures readings below the control measure. This had the potential to affect all facility residents. The facility census was 49.

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to ensure the comprehensive care plan was updated for a fall intervention for Resident #45. This affected one resident (#45) of three residents reviewed for falls. The facility census was 49. Findings Include: Review of Resident #45's medical record revealed she was admitted on [DATE] with diagnoses that included but were not limited to hypertension, insomnia and dementia. Review of facility investigation report dated 01/16/26 revealed Resident #45 was found on the floor mat directly beside her bed and a silent bed alarm was implemented as the immediate action taken for fall. [...]

Inspectors wroteBased on staff interview, review of the medical record, and review of facility policy, the facility failed to ensure baseline weight measurements were obtained and verified in a timely manner after admission. This affected one resident (#7) of one resident reviewed for nutrition and weight loss. The facility census was 49.

Inspectors wroteBased on review of the medical record, interviews, review of Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents drug regimen was free from unnecessary drugs when pain medication parameters were not in place. This affected two residents (#12 and #24) out of three residents reviewed for pain. The facility census was 49.

Inspectors wroteBased on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40.

Inspectors wroteBased on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40.

Inspectors wroteBased on medical record review, hospital record review, interview, observation, review of the mechanical lift instructions, and policy review, the facility failed to use appropriate slings for the mechanical lift and failed to maintain the mechanical lift per the manufacturer's instructions resulting in significant resident injury with mechanical lift transfers. Actual harm occurred on 07/20/25 when Resident #4, who required extensive assistance from two staff members and a mechanical lift with transfers, experienced a fall during a mechanical lift transfer when staff used the incorrect sling and the sling straps broke. The resident was transferred to the emergency room for evaluation and subsequently admitted to the surgical trauma intensive care unit overnight due to multiple rib fractures and a right occipital scalp contusion and hematoma. [...]

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to develop comprehensive care plans for Resident #10, #12, #15, #34, and #41. This affected five residents (#10, #12, #15, #34, and #41) of 18 records reviewed for care planning. The facility census was 45.

Inspectors wroteBased on observation, record review, staff interviews, and resident interviews, the facility failed to ensure all residents received dignified choices to remain in their room. This affected one (Resident #300) out of one resident reviewed for dignity. The facility census was 45.

Inspectors wroteBased on observation, staff interviews, and resident interviews, the facility failed to provide a comfortable, homelike environment for Resident #35. This affected one resident (#35) of six residents reviewed for comfortable living spaces. The facility census was 45. Findings Include: Resident #35 had an admission date of 12/08/20 with diagnoses including retention of urine, hypertension, neuromuscular dysfunction of bladder, age related osteoporosis with current pathological fracture of vertebrae, assistance with personal care, muscle weakness, abnormalities of gait and mobility, insomnia, urinary tract infection, and anxiety disorder. Observations on 11/04/24, 11/05/24, and 11/06/24 revealed a minimum of 11, and a maximum of 12 packages of incontinence briefs stacked and stored along the wall in Resident #35's bathroom. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to document ongoing assessments to evaluate the need for the use of physical restraints. This affected two residents (#28 and #300) of eight residents reviewed for the use of restraints. The facility census was 45.

Inspectors wroteBased on record review, resident family interview, staff interview, and facility policy review, the facility failed to provide the resident or resident representative with a written notice of a bed hold. This affected one (Resident #25) out of two residents reviewed for hospital transfers. The facility census was 45.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #34's dressing changes for a skin tear were completed as ordered. This affected one resident (#34) of two residents reviewed for skin conditions. The facility census was 45.

Inspectors wroteBased on observation and record review the facility failed to ensure the resident environment remained free of accident hazards by safely storing portable oxygen per the facility policy/procedure. This had the potential to affect one (Residents #38) of one resident reviewed. The facility census was 45.

Inspectors wroteBased on record review and interview the facility failed to document nutritional supplement intake and complete an annual nutrition assessment. This affected three (Resident #25, #36 and #41) of eleven reviewed for the use of nutritional supplements. The facility census was 45.

Inspectors wroteBased on record review and staff interview, the facility failed to follow ordered medication administration parameters, and failed monitor a resident for side effects of anticoagulant use. This affected two (Resident #33 and Resident #25) of six resident reviewed for medications. The facility census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately identify and monitor targeted behaviors for residents who use psychotropic medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 45.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to remove, inactivate, or destroy pathogenic organisms on the surface of a multi-use device (glucometer) to the point where it was rendered safe for handling and re-use. This had the potential to affect three residents (#9, #297, #25) receiving glucometer checks on the Skilled Unit. The census was 45.

Inspectors wroteBased on record review and interview the facility failed to follow guidance within their antibiotic stewardship program to ensure antibiotics were ordered appropriately. This affected two (Resident #33 and #101) out of three reviewed for appropriate antibiotic usage. The facility census was 45.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to implement Legionella prevention plan according to the facility water management plan. This had the potential to affect 44 of 44 residents in the facility. Facility census was 44.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, family interview, and policy review, the facility failed to monitor resident's skin impairments and edema. This affected four (#6, #9, #13, and #40) of four residents reviewed for skin impairments. The census was 44.

Inspectors wroteBased on medical record review, resident interview, staff interview, self-reported incident review and facility policy review, the facility failed to timely notify the Administrator and state agency (Ohio Department of Health (ODH) of an alleged incident of abuse/neglect. This affected one (#9) of one resident reviewed for abuse. The census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately reflect resident wounds. This affected two (#19 and #32) of three reviewed for resident assessments. The facility census was 44.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (#19) of one resident reviewed for PASARR. The facility census was 44.

Inspectors wroteBased on observation, medical record review, staff interview and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). There were three medication errors out of 33 opportunities to equal an error rate of 9.09%. This affected three (#4, #6, and #7) of eight residents observed during the medication administration observation. The census was 44. Findings Include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/28/12 and the diagnoses of high blood pressure, diabetes type two, fatigue, and heart failure. Review of the monthly physician orders for February 2022 revealed the resident was ordered a stool softener-laxative twice daily for constipation and the order stated in bright red letters Dose check not performed. There was no medication specified and no dosage specified. Observation on 02/22/22 at 3:16 P.M. [...]