Willowbrook Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 15 residents (Residents #13, #56, and #2) reviewed for resident rights. 1. The facility failed to ensure Resident # 13, and Resident #56 were served breakfast in the dining room in a dignified manner on 7/08/2025.2. The facility failed to ensure CNA K did not stand over Resident # 2 while feeding her on 7/7/25. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and 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 4 residents (Resident #2, #20 and #16) and 4 of 5 staff (CNA A, CNA G, CNA K and CNA F) reviewed for infection control. 1. The facility failed to ensure CNA A properly changed gloves and cleaned her hands during incontinent care for Resident #20 on 7/08/2025.2. The facility failed to ensure CNA G performed hand hygiene between passing of resident #16's tray on hall 500 on 7/8/25.3. The facility failed to ensure CNA F removed soiled gloves and before hand hygiene before exiting Resident #16's room on 7/9/25.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 8 residents (Resident #66) reviewed for MDS assessment accuracy, in that:Resident #66's MDS quarterly assessment dated [DATE] failed to indicate Resident #66 had a physical or verbal behaviors directed or not directed toward others. This failure could place residents at risk of not receiving adequate care and services to meet their needs.

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 receives the necessary services to maintain personal hygiene for 2 of 8 residents (Residents #1 and #42) reviewed for ADL care. The facility failed to clean/groom Resident #1's fingernails that had a dark, brown substance underneath them on 7/7/25 and 7/8/25. The facility failed to trim/file Resident #42's fingernails that were long and jagged on 7/7/25 and 7/8/25. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 12 residents reviewed for quality of care, (Residents #43 and #58:The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #43and #58. This failure could place residents at risk of injuries due to environmental hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 4 (Residents #98) residents reviewed for food to meet nutritional needs. The facility failed to ensure Resident #98 was not served thin liquids on 7/07/2025 and 7/08/2025. This failure could place residents at risk of difficulty swallowing, possibly resulting in choking. Findings Included:Record review of a facility face sheet dated 7/08/2025 revealed Resident #98 was a [AGE] year old male that was admitted to the facility on [DATE] with diagnosis of senile degeneration of brain (mental decline due to age). Record review of Resident #98's admission MDS assessment dated [DATE] revealed Resident #98 had a BIMS of 3 indicating severely impaired cognition and had episodes of difficulty swallowing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 6 residents (Resident #1 and #2) reviewed for pharmacy services. The facility did not ensure medications were stored properly for Resident #1 and #2. Medication was left on bedside table and Residents #1 and #2 are not care planned to have medication at bedside or to self-administer medications. Residents #1 and #2 does not have a physician order to have medication at bed side or to self-administer . These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (Resident #1) residents reviewed for supervision. The facility failed to notify the transport staff Resident #1 resided on the secure unit and had a diagnosis of dementia. The facility failed to ensure adequate supervision was provided during transport for Resident #1 who resided on the secure unit. On 2/19/25 Resident #1 was left unattended in the transport van for approximately 15 minutes in which Resident #1 eloped out of the van and walked down the road 2 blocks and was picked up by a good Samaritan. Resident #1 was located by the police department about 30 minutes later and returned to the facility. An IJ was identified on 3/18/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 (Residents #30, #71, #43) of 16 resident rooms reviewed for environmental conditions in that: The facility failed to ensure Resident #30's resident restroom did not have dark colored splatters on wall next to toilet and strong odor of urine. The facility failed to ensure Resident #71's resident room did not have crumbs in windowsill and splatters on wall. The facility failed to ensure Resident #43's divider curtain was clean and free of splatters and stains. This deficient practice could place residents at risk of living in an unsanitary environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 4 of 19 residents reviewed for quality of care. (Resident #3, #58, #86, and #111). The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen observed for kitchen sanitation. The facility failed to ensure that the kitchen refrigerator did not have unlabeled and expired food on 6/17/24. The facility failed to ensure that the kitchen dry storage area did not have unlabed and expired food on 6/17/24. The facility failed to ensure that the walk in freezer did not contain unlabeled and undated food on 6/17/24. The facility failed to ensure that foods were not stored on the floor of the walk in freezer on 6/17/24. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 7 hallways, hallway 100 and hallway 500 and 2 rooms of 24 rooms (room [ROOM NUMBER]and 506) reviewed for pest control. The facility failed to ensure hallways and resident rooms were free of flies. This failure could place residents at risk of a diminished quality of life due to an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 2 (Resident #86 and Resident #114) of 8 residents whose records were reviewed for assessments. Resident #86 was not coded as dependent with transfers on her 5/15/24 quarterly MDS assessment. Resident #114 was not coded as receiving hospice services on his 3/11/2024 admission MDS assessment. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #111) reviewed for gastrostomy tube management quality of care. The facility failed to ensure Residents #111's enteral feeding was maintained within date per manufacturer label. This failure could place residents who received feedings by gastrostomy tube (tube inserted into the stomach for feeding) at risk for sickness, hospitalization and decline in health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #20) reviewed for medication administration. Resident #20 was not provided ordered clonazepam 1 mg po bid on 06/12/2024, 06/13/2024, 06/14/2024, 06/15/2024, 06/16/2024, and 06/17/2024. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 three compartment sink in the kitchen reviewed for food service in that: On 6/17/2024 the facility did not ensure the 3-compartment sink was in working order. The right sink of the 3-compartment sink was leaking water into a tub underneath and onto the floor. This failure could place residents who eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 16 residents reviewed for call lights. (Resident #90 and Resident #70) The facility failed to ensure Resident #90's and Resident #70's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for nurse staffing information. The facility failed to ensure the daily staffing information was posted on 6/17/2024. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 24 residents (Residents #34 and #50) and 2 of 7 hallways (hallways 200 and 500) reviewed for physical environment. The facility failed to keep hallway 200, 500, Resident #34, and Resident #50 comfortable and free of lingering foul odors. The facility failed to provide needed floor maintenance on hallway 200. These failures could place all residents who reside in the facility at risk of diminished quality of life, discomfort, and risk of injury from being exposed to foul odors and unsafe flooring in areas of the facility inhabited and utilized by the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. There were three filthy pans of water on the floor in the dish room, one under the sink at the garbage disposal, and two under the dish machine. The three pans of water were overflowing on to the floor, and there were food debris and black gunk around the pans. These failures could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to keep cigarette butts out of the trash can in the smoking area and failed to implement their smoking safety policy. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The Findings Included: Record Review of the smoking policy for residents revised 06/2017 revealed,4. Metal containers, with self-closing cover devices, are available in the smoking areas. 5. Ashtrays are emptied only into designated receptacles. Record review of List of smokers undated revealed there was 9 residents listed as smokers. During an observation on 4/17/23 at 04:00 PM, revealed smoking area outside with 2 ashtrays fixed to the wall. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one (Resident #32) of two residents reviewed for catheter care in that: CNA D performed catheter care on Resident #32 using an up and down motion on the catheter tubing with an incontinent care wipe. The same wipe was used to clean the supra pubic insertion site. Resident #32 has history of urinary tract infections. This failure could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (nurse cart 500 hall) reviewed for labeling and storage. The facility failed to remove expired insulin from the nurse medication cart on hall 500. This failure could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.