Willow Brook Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Willow Brook Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 12, 2025

  Based on observations, record reviews and interviews, the facility failed to keep one Resident (#45) free from neglect out of a total sample of 28 residents. Specifically, the facility failed to provide incontinence care to Resident #45 for a total of 10 hours and assisted him/her with a meal while lying in soiled incontinent briefs, resulting in a new skin impairment to the left buttock. Findings include:Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, dated March 2018, indicated the following:-Neglect as defined at 483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.-Along with staff and management, the… […]

• No harm, potential for more than minimal, widespreadF943Sep 8, 2023

  Based on document review and interview, for 9 out of 9 sampled employee personnel files the facility failed to provide annual abuse training for their staff, as required and per facility policy. Specifically, the facility failed to provide in-servicing that included resident abuse prohibition training. Findings include: Review of the facility policy titled Abuse review date 10/23/22 included the following: Training: -Facility personnel will be trained on hire at orientation, bi-annually and as needed on an on going basis Prevention: -The facility will provide staff on orientation, annually and as determined, information on how and to whom they may report concerns, incidents, and grievances without fear of retribution. […]

• No harm, potential for more than minimal, widespreadF947Sep 8, 2023

  Based on record review and interview, the facility failed to ensure that 5 of 5 staff reviewed received 12 hours of mandatory in-service training in a year. Findings include: Review of 5 Certified Nursing Assistants (CNA) employee records indicated that 5 out of 5 employees did not complete the mandatory 12 hours of education required. During an interview on 9/8/23 at 12:30 P.M., The Director of Nursing and the Human Resources Representative said the facility attempted to locate staff training records and could not find any proof that the required in-service training had been done by staff. During interviews on 9/8/23 between 1:36 P.M., and 1:44 P.M., CNA #3, CNA #4, and CNA #6 said they have not received any in-service education in the past 2 years. […]

• No harm, potential for more than minimal, patternF677Sep 12, 2025

  Based on observation, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 Residents (#45, #109, and #7) out of a total sample of 28. Specifically;1.) For Resident #45 the facility failed to provide incontinence care for the entirety of an over-night shift and the start of the morning shift, equaling a total of ten hours, resulting in skin breakdown;2.) For Resident #109 the facility failed to ensure cueing or assistance was provided for meals, resulting in Resident #109 eating 4 of 4 meals, that were not finger foods, with his/her hands; and 3.) For Resident #7, the facility failed to provide assistance with meals. […]

• No harm, potential for more than minimal, patternF686Sep 12, 2025

  Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, and/or interventions to promote healing and prevent new ulcers from developing for four Residents (#45, #2, #17, and #23), who had pressure ulcers, out of 28 total sampled residents. Specifically,1a.) For Resident #45, the facility failed to implement a wound intervention resulting in deterioration of wound,1b.) For Resident #45, the facility failed to ensure staff provided prompt incontinence care to prevent new skin breakdown,2a.) For Resident #2, the facility failed to address and implement wound clinic recommendations for pressure ulcers to right and left buttocks, 2b.) For Resident #2, the facility failed to assess and document the measurements of the right and left… […]