Willowbrooke Ct Skilled Care Ctr at Bayleigh Chase

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service. This was evident during the initial tour of the kitchen during the recertification/complaint survey.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to ensure that call bells were kept within residents' reach. This was evident for 2 (Residents #8 and #60) of 60 residents observed during the recertification survey.

Inspectors wroteBased on interview, observation, and review of facility documents it was determined the facility failed to maintain an effective grievance program. This was evident for 1 (Resident #43) of 4 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on a review of facility records, medical records, and staff interviews, it was determined that facility staff failed to report an allegation of potential abuse immediately. This was evident for two (Resident #18 and #72) of five residents reviewed for allegations of abuse during this recertification/complaint survey.

Inspectors wroteBased on a medical record review, a facility investigation review, and staff interviews, it was determined that the facility failed to thoroughly investigate allegations regarding an injury of unknown origin. This was evident for one (Resident #39) of 9 residents reviewed for self-reported incidents during this recertification/complaint survey.

Inspectors wroteBased on observation, record reviews, and interviews, it was determined that the facility failed to ensure that the resident's environment remained free of potential accident hazards. This was evident for 1 (Resident #15) of 5 residents reviewed for accident hazards during the recertification/complaint survey process. The findings Included:BIMS The Brief Interview for Mental Status (BIMS) is a 0-15 point assessment tool used to measure cognitive function of long-term care residents. Scores categorized as 13-15 (intact), 8-12 (moderate impairment), or 0-7 (severe impairment). The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. On 03/23/2026 at 8:49 AM, during the initial facility tour, the surveyor observed three unattended white pills in a small medication cup on Resident #15's bedside table. [...]

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to provide appropriate pain management. This was evident for 1 (Resident #57) out of 1 residents reviewed for pain during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to have an effective collaborative communication process for residents receiving hospice services. This was evidenced for 1 (Resident #30) of 1 Resident reviewed for hospice services during the recertification/complaint survey. Findings Included:On 03/24/2026 at 8:44 AM, a care plan review confirmed that Resident #30 was receiving hospice services. On 03/24/2026 at 9:58 AM, in an interview with the Director of Nursing (DON), she was asked about the resident's treatment goals and she reported being unsure of the treatment goal for Resident #30 and was also uncertain about where hospice communication was documented (electronic health record or paper). [...]

Inspectors wroteBased on facility reported incidents, record review and interview with facility staff it was determined that the facility staff failed to protect residents against incidents of abuse, and ensure measures were put in place to prevent further incidents of abuse. This was evident for 3 (#905, #901, and #45) of 9 residents reviewed for abuse. The facility was notified of the immediate jeopardy at 4:40 PM on 1/13/25. The facility developed a plan to sufficiently remove immediacy, which was reviewed and accepted after 3 attempts, at 6:37 PM on 1/13/2025 while surveyors remained onsite. The plan to remove immediacy that was presented to surveyors included: Resident #905 passed on 8/2/23, Resident #901 passed on 2/22/23. Resident #45 was interviewed on 1/8/25 by the social worker regarding his/her abuse claim. The facility reported the incident to the state on 1/8/25. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R)52) of two residents reviewed for falls out of a total sample of 27 residents had root cause analysis and a thorough investigation completed to determine if additional interventions were warranted when the resident had 11 falls, one resulting in harm when the resident sustained a left hip fracture requiring surgery. This had the potential for the resident to continue to have falls with possible major injuries.

Inspectors wroteBased on review of staff records and interview with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months. This was evident for all GNA's working in the facility since 2022 and has the potential to affect all residents. Failure to perform performance reviews prevents the facility from providing regular in-service education that is based on the outcome of these reviews. The evidence includes: The employee file of GNA#7 was reviewed on 1/13/25 at 9:30 AM, during review of a facility reported incident (#MD00182604) related to abuse. No performance reviews were found in the file. Upon request, the Director of Nursing (DON) provided the last 3 reviews for GNA#7 which were dated 1/27/09, 9/4/09 and 10/26/11. [...]

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential to affect all residents of the facility who consumed food from the kitchen, with the exception of one resident who was nothing by mouth (NPO).

Inspectors wroteBased on interview and review of facility documentation, the Quality Assurance (QA) committee failed to complete a thorough Performance Improvement Project (PIP) that was a continuous improvement of processes, measured outcomes, develop, and implemented action plans, measured success, and contained a root cause analysis. This failure had the potential to affect all 55 residents in the facility by not identifying problems that impact their quality of life, quality of care, and resident safety.

Inspectors wroteBased on staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1. Failure to have a system in place to effectively complete investigations related to injuries of unknown origin, 2. Failure to address abuse and further identify/address potential/alleged abusers, and 3. Failure to ensure that all staff received required training for abuse. [...]

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure that all nursing staff received training on abuse which included procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 1 (#905) of 9 residents reviewed for Abuse.

Inspectors wroteBased on medical record review, review of facility reported incidents and interview with facility staff, it was determined that the facility administration failed to report all reportable incidents to the Office of Health Care Quality (OHCQ) no later than 2 hours after alleged abuse incidents occurred and/or injuries of unknown origin meeting the regulatory criteria. This was evident for 7 (#903, #902, #904, #901, #905, R45,and R211) of 12 residents reviewed for abuse with additional occurrences found during the individual review of the resident's medical records that too were not reported to the state agency, and failed to report an allegation of abuse to local law enforcement for 1 (#901) of 9 residents reviewed for abuse.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to thoroughly investigate allegations of abuse and injuries of unknown origin, and failed to protect residents from further abuse. This was evident for 7 (#902, #903, #904, #901, #905, R45, and R45) of 12 residents reviewed for abuse with additional occurrences found during the individual review of the resident's medical records that were not previously identified by the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of six observed residents (Resident (R)27) physician's orders had been followed for the removal of two lidocaine patches out of a total sample of 27 residents. This had the potential for the resident to have adverse reactions of patches being left on too long.

Inspectors wroteBased on medical record review and interview with facility staff, and after the review of multiple facility reported incidents, it was determined that the facility failed to administer and document pain medication for residents with reported pain. This was evident during the review of 2 of 3 residents with reported falls and pain. (#903 and #902)

Inspectors wroteBased on review of the medical record and interview with staff it was determined the facility staff failed to maintain complete and accurate medical records. This was evident for 1 (#901) of 9 residents reviewed for Abuse.

Inspectors wroteBased on medical record review, interview of residents, family and facility staff, it was determined that the facility failed to: 1) review, and update residents care plans based on changes related to their individual plan of care; 2) update a resident's care plan to address his/her history of escalating wandering behaviors associated with the gradual dose reduction of Seroquel and 3) have care plan meetings involving members of the interdisciplinary team to include dietary and geriatric nursing assistant responsible for the resident. This was evident for 5 out of 23 residents (Resident #41, #44, #24, #23 and #55) reviewed during the investigative stage of the survey.

Inspectors wroteBased on review of posted staffing and interview with the Director of Nursing (DON) it was determined that the facility failed to identify a charge nurse other than the DON.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to include the required statement of the resident's appeal rights and Ombudsman contact information in the written notice of transfer. This was found to be evident for 1 out of 2 residents (Resident #47) reviewed for hospitalization during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that Resident #1's Minimum Data Set assessment was not submitted regarding the resident's discharge. This was evident for 1 of 1 resident (Resident #1) reviewed for the resident assessments during the investigative stage of the survey.

Inspectors wroteBased on observation, medical record review and interview with the facility staff it was determined that the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failure to accurately assess behavior; 2) failure to assess the resident health condition-falls. This was evident for 2 out of 23 (R #6 and #32) records reviewed during the investigation stage of the survey.

Inspectors wroteBased on interview with resident, staff and observation it was determined that the facility failed to provide activities to all residents equally that were admitted to the facility.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to: 1) maintain observation of a cognitively impaired resident who was later found outside of the facility unsupervised and 2) conduct a timely re-assessment of the resident's risk for wandering or elopement after he/she was found to have exited the facility unattended. This was evident for 1 of 20 residents (Resident #24) reviewed during survey investigation.

Inspectors wroteBased on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass by 2 nurses and 4 residents with 30 medication opportunities.

Inspectors wroteBased on tour and observation it was determined that the facility failed to maintain a secure store room. This was evident during a random tour of the facility.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to document a resident's wandering behaviors in the medical record. This was evident for 1 of 23 residents (Resident #24) reviewed during survey investigation.

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to provide proper ventilation for residents. This was true for 1 of 2 bathing spas (Chop Tank) that were in the facility.