Cherith Care Center at Willow Brook

In the surveyor’s words

From the most serious findings on record at Cherith Care Center at Willow Brook, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727May 28, 2025

  Based on review of the payroll based journal (PBJ), staff interviews and record review, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours, seven days a week. This had the potential to affect all facility residents. Facility census 30. Findings include Review of the PBJ report from the review period of 10/01/24 to 12/31/24 revealed the facility triggered for no RN for at least eight hours a day, seven days per week. Review of the registered nurse schedule for October 2024 revealed on 10/05/24, 10/06/24, 10/19/24, and 10/20/24 the facility had no RN working in the nursing home. Review of the registered nurse schedule for November 2024 revealed on 11/02/24, 11/03/24, 11/16/24, 11/17/24 and 11/30/24 had no RN working in the nursing home. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2023

  Based on observations, staff interview and review of the facility policy, the facility failed to ensure safe and sanitary food storage in the refrigerator and freezer in the main kitchen area. This had the potential to affect all 31 residents residing in the facility who received food from the kitchen. Findings include: Observations on 05/01/23 at 9:56 A.M. of the kitchen revealed a cup of creamer or milk left uncovered and had spilled on a tray in the refrigerator; a pre-made plate of sausage with peppers and onions was left undated in the refrigerator; coconut shrimp was in an individually sized portioned zip lock bag and was left open to air in the freezer; a pack of veggie burgers were left open to air in the freezer; a bag of rice was on top of a container with rice bags inside of it. […]

• No harm, potential for more than minimal, isolatedF605Apr 23, 2026

  Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents had appropriate indications for use of antipsychotic medications. This affected one (Resident #21) of two residents reviewed for psychotropic medication use. The census was 32.Findings Include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, restlessness and agitation, osteoarthritis, hypertension, hyperlipidemia, hypothyroidism, dysphagia, edema, vitamin D deficiency, and unspecified protein calorie malnutrition. […]

• No harm, potential for more than minimal, isolatedF849Apr 23, 2026

  Based on medical record review and staff interview, the facility failed to ensure hospice provider documentation, including plans of care, assessments, and care notes, were provided to the facility in a timely manner to ensure the continuity of resident care. This affected one (Resident #3) of one residents reviewed for hospice services. The facility census was 32.Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/29/25 with diagnoses including Alzheimer's disease, pulmonary hypertension, history of transient ischemic attack, traumatic fracture, chronic diastolic heart failure and sepsis.Review of the hospice admission consent dated 01/12/26, signed by Resident #3's representative, revealed consent was provided to initiate for hospice… […]

• No harm, potential for more than minimal, isolatedF582May 28, 2025

  Based on record review, interview and policy review the facility failed to include all required information on the skilled nursing advanced beneficiary notice (ABN). This deficient practice affected two (Resident #14 and Resident #238) of three residents reviewed for cut letters. The facility census was 40. Finding include: 1. Review of the medical record for Resident #238 revealed an admission date of 02/16/2025. Diagnoses included dementia, difficulty walking, chronic kidney disease, adult failure to thrive, dementia, pressure ulcer of the sacral region, abnormal weight loss, encephalopathy, cognitive communication deficit, and Parkinson's disease. […]