Willow Brook Christian Home

In the surveyor’s words

From the most serious findings on record at Willow Brook Christian Home, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 2, 2025

  Based on medical record review, hospital record review, interview, observation, review of the mechanical lift instructions, and policy review, the facility failed to use appropriate slings for the mechanical lift and failed to maintain the mechanical lift per the manufacturer's instructions resulting in significant resident injury with mechanical lift transfers. Actual harm occurred on 07/20/25 when Resident #4, who required extensive assistance from two staff members and a mechanical lift with transfers, experienced a fall during a mechanical lift transfer when staff used the incorrect sling and the sling straps broke. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based on review of the Legionella plan, policy review and staff interview, the facility failed to ensure the Legionella plan parameters for temperature readings were followed and failed to ensure new interventions were initiated for documented temperatures readings below the control measure. This had the potential to affect all facility residents. The facility census was 49. Findings include: Review of the Legionella plan dated 07/2025 revealed the facility shall check the outflow and return temperatures of the domestic water heaters. The domestic water heaters had control temperatures of 118 degrees Fahrenheit (F) for the county water and 140 degrees F for the city water. […]

• No harm, potential for more than minimal, widespreadF880Feb 28, 2022

  Based on record review, staff interview, and policy review, the facility failed to implement Legionella prevention plan according to the facility water management plan. This had the potential to affect 44 of 44 residents in the facility. Facility census was 44. Findings include: Review of the Legionella maintenance plan revealed weekly maintenance plans included weekly water temperature logs of cold water systems, hot water systems, hot water boilers and hot water tanks. The maintenance plan revealed weekly visual inspection of the spa tubs. The maintenance plan revealed monthly visual inspections to be completed of the showerheads and aerators and quarterly plans for visual inspections of the ice machines, water dispensers, and drinking fountains. […]

• No harm, potential for more than minimal, patternF656Nov 7, 2024

  Based on record review, interview and review of facility policy, the facility failed to develop comprehensive care plans for Resident #10, #12, #15, #34, and #41. This affected five residents (#10, #12, #15, #34, and #41) of 18 records reviewed for care planning. The facility census was 45. Findings include: 1. Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF684Feb 28, 2022

  Based on observation, medical record review, resident interview, staff interview, family interview, and policy review, the facility failed to monitor resident's skin impairments and [CONDITION(S)]. This affected four (#6, #9, #13, and #40) of four residents reviewed for skin impairments. The census was 44. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required limited assistance of one staff for bed mobility, extensive assistance of one staff for transfers, locomotion, toilet use and personal hygiene. […]