Champions Healthcare at Willowbrook

In the surveyor’s words

From the most serious findings on record at Champions Healthcare at Willowbrook, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Feb 25, 2025

  48559 Based 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. […]

• Immediate jeopardy, isolatedF684Apr 13, 2022

  Based on observations, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 5 residents (CR #1) reviewed for quality of care. 1. The facility failed to transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff transcribed 30 ml four times per day. This error was not recognized until 3/28/2022 . 2. The facility failed to consult the physician when new orders were received to change the medicine dose on 3/29/2022. […]

• Immediate jeopardy, isolatedF692Dec 30, 2021

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for two of 11 (Resident #1 and Resident #2) residents reviewed for weight loss/ nutrition/ hydration status. The facility failed to timely identify and assess Resident #1 for change in condition of weight loss when Resident #1 lost 21 pounds from 12/09/21 to 12/21/21 according to the resident's weight summary. Resident #1 labs on 12/21/21 reflected high creatinne level. […]

• Actual harm, isolatedF600Apr 23, 2026

  Based 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. Findings included:Record review of Resident #35's undated face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] with a recent admitted date of 04/15/2026. […]

• Actual harm, isolatedF677Apr 23, 2026

  Based 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.Findings included:Record review of Resident #66's face sheet dated 08/23/26 revealed a [AGE] year-old female who admitted to the facility on [DATE]. […]