Willowbrook Manor

Inspectors wroteThis Citation Pertains to Intake Number 2786215. Based on interview and record review, the facility failed to provide medications as ordered for one resident (Resident #1) of three residents reviewed for medication administration. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Diabetes, hypothyroidism, arthritis, Dementia, history of falls, low back pain, hypertension, history of a stroke and urinary tract infection/UTI. The resident discharged to home on 2/27/2026. A review of the progress notes for Resident #1 indicated she was admitted to the facility on [DATE] at approximately 2:45 PM and a provider note by Nurse Practitioner E dated 1/8/2026 listed her medications including: Nitrofurantoin microcrystal, oral capsule 100 mg: [...]

Inspectors wroteThis Citation pertains to Intakes 2713005 and 2717874. Based on observation, interview and record review, the facility failed to fulfill residents' rights with timely responses to call lights for five Residents (#1, #3, #4, #5, and #6) of six residents reviewed for residents' rights and call light response times.

Inspectors wroteThis Citation pertains to Intake Number 2717874. Based on observation, interview and record review, the facility failed to ensure that physicians' orders for oxygen use were followed for 1 resident (Resident #6),; oxygen was provided to 1 resident (Resident #5); and nebulizer equipment was stored properly for 1supplemental (Resident #7), of three residents reviewed for oxygen administration and one supplemental resident.

Inspectors wroteThis Citation pertains to intake Number 2659743. Based on interview and record review, the facility failed to transfer to the hospital in a timely manner one resident (Resident #1) of 1 resident reviewed for a delay in transfer to the hospital, upon an acute change of condition. Findings Include:On [DATE] at 9:15 AM, EMT (Emergency Medical Technician)/ LPN (Licensed Practical Nurse) C shared they were dispatched to the facility around 1:30 AM on [DATE] for a male resident with difficulty breathing, pulse of 150 and unresponsiveness. Upon arrival the nurse informed them she had recently arrived for her shift and per Resident #1's brother he had been in this condition prior to the beginning of her shift. The CNA (Certified Nurse Assistant) was sitting at the edge of the resident's bed and shared this was not his baseline and the night prior this was not how Resident #1 presented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are treated in a dignified manner by timely call light response by staff and accessible to residents, maintain food palatability for two (2) Residents #58, #21, and a confidential group of residents resulting in residents needs not met, frustration, embarrassment and potential for skin impairment from being left soiled and wet for prolonged periods.

Inspectors wroteBased on interview and record review, the facility failed to provide prompt efforts to resolve complaints pertaining to prolonged call light response times, food palatability, bedtime (HS) snack distribution, group activities, and staff availability and attitude to assist and to ensure the process to address grievances was understood for nine (9) confidential group of residents resulting in unresolved grievances and potential for further frustration.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a substantial HS (evening) snack was consistently offered and appropriately distributed to a group of confidential residents that attended the Resident Council Meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between last evening meal and breakfast the following day, resulting in resident dissatisfaction, frustration and potential for uncontrolled blood sugars, signs and symptoms of hypoglycemia, feeling of hunger, and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen that included: 1.) outdated food in the refrigerator; 2.) maintaining proper temperature of refrigerators and freezers; 3.) proper labelling of food items with a use by date; 4.) ensure dented cans were removed from supply; 5.) ice scooper not placed appropriately at the ice machine; and 6.) ensure the temperature log for refrigerator and freezer were not documented in advance. This deficient practice has the potential to affect all residents who consume food prepared by the facility of a census of 108.

Inspectors wroteResident #43: Advance Directives A record review was conducted on [DATE] at 10:15 AM. According to the Electronic Medical Record (EMR), R43 was [AGE] years old, admitted to the facility on [DATE], with the primary diagnosis of Cerebral Infarction, dysphagia Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis affecting Right dominant side and vascular dementia in addition to another diagnosis. R43 was enrolled in hospice services and has an appointed guardian. R43's Minimum Data Set (MDS) assessed on [DATE] revealed that her Brief Interview for Mental Status score is 00/15. A score of zero generally indicates severe cognitive impairment. MDS section GG indicated that R43 was dependent on all Activities of Daily Living (ADLs), especially personal hygiene tasks and mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that blood pressure medications were administered as ordered for one resident (#209) of 6 residents reviewed for medications and a wound treatment was administered per physician's recommendation for one resident (#42) with a facility acquired wound of 2 residents reviewed for skin conditions. Findings Include: Resident #42: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #42 was admitted to the facility on [DATE] with diagnoses: Osteomyelitis (bone infection) of the right foot and ankle, Pressure ulcer sacrum unstageable, history of lung cancer, COPD, Morbid obesity, weakness, Chronic pancreatitis, and Gout. [...]

Inspectors wroteResident #81: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #81 was admitted to the facility on [DATE] with diagnoses: Heart failure, COPD, mild protein-calorie malnutrition, anxiety, and difficulty walking. On 6/24/2025 at 11:20 AM, Resident #81 was observed sitting in his room in bed. When asked about his meals at the facility, he said he was supposed to receive double portions of meat, but did not always receive them. He said he had talked to the Nurse Practitioner/NP and Unit Manager about it, but it didn't change anything. During the interview with Resident #81 on 6/24/2025 at 11:20 AM, he said the previous night, there were no hotdogs or hamburgers as an alternative to the regular menu. He said he was told by the staff they were out of them. The resident said he had to eat very greasy, grilled cheese. [...]

Inspectors wroteThis Citation pretains to Intake Number MI00153408. Based on observation, interview and record review, the facility failed to obtain dental services timely for a Resident who received a partial denture for the bottom teeth that were ill-fitting, and unable to be used by the resident who had problems with chewing some foods for one resident (#84) of two residents reviewed for dental services.

Inspectors wroteThis Citation pertains to Intake Number MI00150954. Based on interview and record review the facility failed to timely obtain new prescription to reorder pain medication for one resident (#801) of two residents reviewed for pain management and pharmacy procedures, resulting in, Resident #801 going without her patch for three days and increased pain.

Inspectors wroteThis Citation pertains to Intake Number MI00147318. Based on observation, interview and record review the facility failed to assess and monitor intravenous medication therapy per professional healthcare standards and a provider's order for two residents (Resident #702 and Resident # 703) of two residents reviewed for intravenous antibiotic therapy, resulting in Resident #703 being administered two doses of Vancomycin after elevated levels were received and a lack of monitoring and dosing of Resident #702's Vancomycin. Findings Include: Resident #702: On 10/15/2024 at approximately 4:00 PM, a review was conducted of Resident #702's medical records and it revealed the resident admitted to the facility on [DATE] with diagnoses that included, Necrotizing Fasciitis, Hypertension, Peripheral Vascular Disease, Stage 3 Kidney Disease and Supraventricular Tachycardia. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00145623 and MI00145776. Based on observation, interview and record review, the facility failed to ensure that wounds were assessed, monitored, and appropriate interventions were in place for one resident (Resident #3) of 3 residents reviewed for wounds, resulting in Resident #3 developing a wound on the left foot great toe, left foot third toe and right foot third toe. Findings Include: Resident #3: On 9/16/2024 at 4:00 PM, Resident #3 was observed lying in bed in her room. She was awake, alert and very talkative. The resident was observed to have thick socks on. A review of the Face sheet and Electronic Medical Record (EMR) indicated that Resident #3 was admitted to the facility with the following diagnoses: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00145623. Based on observation, interview and record review, the facility failed to provide necessary management of an indwelling urinary catheter for one resident (Resident #4) of 3 residents reviewed for urinary catheters, resulting in staff being unaware if Resident #4 had a urinary catheter. Findings Include: Resident #4: A record review of the Face sheet and Minimum Data Set (MDS) assessment, indicated Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses: Heart disease, Bipolar disorder, diabetes, left leg below the knee amputation, peripheral vascular disease, COPD, asthma, history of seizures, hypertension, neuromuscular dysfunction of the bladder, chronic pain, depression and anxiety. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed some assistance with care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, and maintain equipment and plumbing in good repair, resulting in an increased risk of food borne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that accurate advance directive information was in place for two residents (Resident #88, Resident #182) of two residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) from a total sample of 24 residents, resulting in potential for a resident's preferences for medical care not to be followed by the facility. Findings Include: Resident #182 (R182): Review of the medical record revealed R182 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, repeated falls, dementia, pain in right leg, peripheral vascular disease (PVD), heart failure, hyperlipidemia (high fat content in blood), hypothyroidism (low activity of thyroid gland), muscle weakness, and anemia (low red blood cells). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of one residents (Resident #81) an assessment was completed for a half lap tray, and including the rational for the use of the lap tray. Findings Include: \Resident #81 (R81): Resident #81 (R81) was observed to have a half lap tray attached to his wheelchair on 5/30/2024 at 1:36 PM. In an observation on 6/04/2024 at 10:40 AM, R81 was observed to have a half lap tray attached to his wheelchair. Review of a Physician's order dated 9/7/2021, revealed R81 was ordered to have a half lap tray on his wheelchair at all times every day and evening shift for lap tray. The order did not specify what medical symptom the half lap tray was being used for R81. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for two out of 24 residents (Resident #26, Resident #81). Findings Include: Resident #26 (R26): Review of Physician's orders revealed R26 was ordered to receive Seroquel (treats schizophrenia, bipolar disorder, and depression), 25 mg (milligrams) once a day for mood disorder. The orders also revealed R26 was ordered to receive Zoloft (treats depression, obsessive-compulsive disorder, posttraumatic stress disorder, anxiety, and panic disorders) 50 mg one time a day. Review of R26's diagnoses list revealed R26 had diagnoses of visual hallucinations and depression. Review of R26's care plans revealed a care plan with a Focus of (R26) is at risk for adverse reactions and side effects r/t (related to) receiving an Antidepressant and Antipsychotic. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care for Activities of Daily Living (ADL) for three of three residents reviewed for ADL care of dependent residents (R80, R91 and R32), from a total of 24 sampled residents, resulting in not achieving and/or maintaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to perform dressing changes as ordered and 2) Failed to follow physician's orders for removal of a peripherally inserted central catheter (PICC) for one resident (Resident #74) of 24 residents reviewed for quality of care, resulting in the potential for an infection and feelings of frustration and worthlessness.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to implement interventions to promote pressure ulcer healing and prevent the worsening of pressure ulcers for one resident (Resident #37) and 2) Failed to prevent a pressure ulcer for two residents (Resident #37, Resident #91) of three residents reviewed for pressure ulcers, resulting in facility-acquired pressure ulcers and the potential for delayed wound healing and/or the worsening of wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that necessary behavioral health care interventions were implemented for one resident (Resident #32) of 1 resident reviewed for behavioral and emotional needs, resulting in the potential for worsening signs and symptoms of depression, ongoing mental distress, isolation, and the potential for a decline in physical functioning.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was less than 5% when six medication errors were observed form a total of 29 opportunities for two residents (Resident #64, Resident #186) of five residents reviewed for medication administration, resulting in a mediation error rate of 20.69% Findings Included: Resident #186 (R186): Review of R186 Medication Administration Record (MAR) demonstrated Insulin Lispro 100 unit/ml (milliliter) VL (vial) 10 ml. Inject as per sliding scale: if 100-150=0 units; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units if blood sugar is less than 70 or greater than 400 contact physician. Subcutaneously before meals and at bedtime for DM II (Diabetes Mellitus). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error for one resident (Resident #33) of 1 resident reviewed for medication errors resulting in Resident #33 not receiving a prescribed medication and the potential for a worsening infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food at the preferred temperature for one resident (Resident #57) of two residents reviewed for food palpability, resulting in dissatisfaction during meals. Findings Include: Resident #57 (R57): Review of the medical record revealed R57 was admitted to the facility on [DATE] with diagnoses that included insomnia, depression, heart failure, arthritis, peripheral vascular disease (PVD), chronic pain syndrome, history of falling, weakness, hypertension, hyperlipemia (high fat content in blood), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed R57 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 05/29/2024 at 01:45 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice services for one resident (Resident #59) of one resident reviewed for Hospice Services, resulting in the potential of care not being provided to a resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included Resident #59 (R59): Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), weakness, gastro-esophageal reflux, seizures, hypotension (low blood pressure), anxiety, traumatic brain injury, and malignant neoplasm of prostate (cancer of the prostate). [...]

Inspectors wroteThis Citation pertains to intake MI00138800. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management for two residents (Resident #704 and Resident #710) of two residents reviewed, resulting in a lack of implementation and documentation of meaningful, resident-centered interventions for pressure ulcer prevention, the development and worsening of facility-acquired pressure ulcers, unnecessary pain, and the likelihood for a decline in overall heath status.

Inspectors wroteThis Citation pertains to Intake MI00141928. Based on observation, interview and record review, the facility failed to ensure monitoring and accessibility of non-expired and necessary emergency medical equipment and supplies in two of two emergency medical response carts resulting in expired and unsanitary emergency medications and medical supplies, lack of easily accessible, critical, and consistent equipment and supplies during an emergency situation and the likelihood for delay of care and deterioration of all resident(s) experiencing an emergency medical situation.

Inspectors wroteThis Citation pertains to Intake Numbers MI00144106 and MI00143864. Based on observation, interview, and record review, the facility failed to ensure an environment free of abuse by a staff member for three residents (Resident #702, Resident #709, and Resident #711) of three residents reviewed, resulting in a lack of administrative oversight to identify and monitor for increased risk of abuse by staff, and prevent abuse. As a result of this deficient practice, Resident #709 experienced verbal abuse and neglect, and Resident #702 and Resident #711 experienced physical abuse, including intimidation, and the likelihood for feelings of fear and emotional distress utilizing the reasonable person concept.

Inspectors wroteThis Citation pertains to Intake Number MI00141163. Based on observation, interview and record review the facility failed to 1) Monitor blood glucose levels and signs/symptoms of diabetic complications; 2) Recognize a change of condition in a timely manner; 3) Document clinical assessment of a resident during a change in condition and the subsequent measures taken; and 4) Provide documented clinical interventions, care plans and coordination for consistent refusal of all medications since readmission for one resident (Resident #902). [...]

Inspectors wroteThis Citation pertains to Intake Number MI00141348. Based on observation, interview and record review the facility failed to 1) Implement meaningful fall interventions; 2) Complete a Neurological Record and 15-minute checks after falls; and 3) Investigate and complete root cause analysis of falls for one resident (Resident #901), resulting in, Resident #901 falling three times in short succession, without appropriate investigation, intervention and follow through. Findings Include: Resident #901: On 12/19/2023 at 4:15 PM, Resident #901 was observed sleeping peacefully in this room with a facility sitter in the chair next to him. The CNA (Certified Nursing Assistant) stated the resident is 1:1 on all shifts due to his falls. On 12/19/2023 at approximately 4:25 PM, an interview was conducted with Nurse A regarding Resident #901's fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcers for 2 residents (Resident #42 and Resident #72) and ensure that residents were assessed, monitored, wound care was provided as ordered and appropriate interventions were in place for 3 residents (Resident #42, Resident #72 and Resident #262) of 5 residents reviewed for pressure ulcers, resulting in Resident #42 developing a Stage 2 sacral pressure ulcer, Resident #72 developing multiple Stage 2 pressure ulcers to the sacrum and right trochante,; and Resident #262 developing a sacral pressure ulcer that worsened to a Stage 4. Findings Include: Resident #262: Pressure Ulcer/Injury: On 6/14/23 at 10:36 AM during a tour of the facility, Confidential Person M said the resident had a large pressure ulcer on her bottom. He said it was smaller and then became much larger; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain 1) sanitary non-food contact surfaces, 2) plumbing in good repair, 3) properly cool food, and 4) maintain food temperature logs for serve ready foods, resulting in potential contamination of food and the physical facility, affecting all residents who consume food from the kitchen.

Inspectors wroteThis Citation pertains to Intake Number MI00134303. Based on observation, interview and record review, the facility failed to ensure that residents were treated with respect and dignity by not answering call lights timely, meals not served at a palatable temperature and dislikes not taken into account, care not provided with dignity and respect, and that a change of clothing was provided, for four residents (Resident #13, Resident #42, Resident #49, Resident #53) on the initial tour of the survey, and resident from the Confidential Group of Residents, of 22 Residents reviewed for treatment with dignity and respect, resulting in long call light wait times for care, staff use of personal phone while providing resident care, unmet care needs, meals not eaten, feelings of frustration, embarrassment, worthlessness and being belittled, and the potential for weight loss, dissatisfaction with [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable and home-like environment to ensure that hallways, resident rooms, floors and other facility areas and equipment were clean, uncluttered, in good repair and free of ants resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: On 6/14/23 at 9:45 AM, during the initial tour of the building and again on 6/15/2023 and 6/16/2023, multiple resident rooms on the 400 hall were extremely cluttered with clothes and other items piled on the floor and surfaces. Some residents had containers and cartons of food and drink stored on the floor and some residents had trash on the floor. Some of the room had little space to walk beside some sides of the bed as items were piled on the floor. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement comprehensive care plans for three residents (Resident #16, Resident #28 and Resident #61) of 30 residents reviewed, resulting in Resident #16 lacking a care plan to address a need for dental services due to a cracked tooth; Resident #28 did not have a care plan to address breathing treatments, and Resident #61 lacked a care plan to address oxygen therapy and a left leg cast. Findings Include: Resident #16 : On 6/14/23 at 9:54 AM, Resident #16 was observed in her room lying in bed awake. She said she had a cracked tooth and pointed into her mouth. Resident #16 said she was supposed to go to the dentist today, but the bus did not show up. Nurse AA entered the resident's room and said the resident's son had scheduled the appointment and transportation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plans in a timely manner with changes of condition for three residents (Residents #4, Resident #71, Resident #262), resulting in missed revision and interventions necessary for care and services not being care planned with the likelihood of unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) Sanitary storage of nebulizer equipment for Residents # 28, #48, #84 and #312 and 2) Monitoring during respiratory treatment through a tracheostomy tube for Resident #48, of seven residents reviewed for respiratory care, resulting in the potential exposure to infectious organisms, respiratory infections, and adverse reactions left unnoticed and untreated.

Inspectors wroteBased on interview and record review, the facility failed to transmit discharge Minimum Data Set (MDS) assessments timely for three residents (Resident #55, Resident #89 and Resident #94), resulting in late MDS transmissions.

Inspectors wroteThis Citation pertains to Intake Number MI00134303. Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were documented as provided and evaluated to maintain and promote the Resident's abilities to maintain optimal physical functioning for two residents (Resident#13 and Resident #30) of three residents reviewed for range of motion, resulting in not receiving planned services to maintain their current level of functionality and mobility and the potential to have a decrease in physical mobility, range of motion and an overall decrease level of functioning.

Inspectors wroteThis Citation pertains to Intake Number MI00136186. Based on observation, interviews and record reviews, the facility failed to document neuro checks after an unwitnessed fall for one resident (Resident #210), resulting in the likelihood for a decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor urinary catheters for two residents (Resident #4, Resident #53) of three residents reviewed for urinary catheters, resulting in cross contamination, purple bag syndrome with the likelihood of infection.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure narcotic reconciliation was completed accurately, 2) Failed to ensure a medication narcotic drawer was free of pre-drawn narcotics (Morphine) and 3) Failed to to ensure the 300-Hall medication cart was free of loose pills, resulting in unkept medication carts, the likelihood of narcotic drug diversion going unnoticed and the likelihood of medication errors.

Inspectors wroteBased on observation, interview and record review the facility 1) Failed to operationalize the Infection Control program; 2) Failed to ensure proper PPE in a contact isolation for Resident #26; 3) Failed to prohibit the use of multidose soap for resident care going room-to-room, and 4) Failed to assess purple bag syndrome (urinary catheter) for Resident #4, resulting in the lack of data analysis of the Infection Control program for the month of March 2023, likelihood for cross contamination of organisms and the identification of purple bag syndrome in a urinary catheter.