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.

• Immediate jeopardy, isolatedF694Mar 27, 2026

  Based on select facility policy review, clinical record review, review of Centers for Disease Control (CDC) guidelines, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate measures for the care and management of a midline peripheral venous access device (a vascular access tool inserted into an upper arm vein to serve as an alternative to a shorter IV for treatment) in accordance with facility policy and professional standards of practice for one of three residents (Resident 8). […]

• Actual harm, isolatedF689Jun 18, 2026

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to prevent accidents related to falls for one of four sampled residents which resulted in actual harm of a left femoral neck fracture (broken hip). (Resident 1)Findings include: Review of the facility policy entitled, Fall Risk Policy, last reviewed February 23, 2026, revealed that they would complete and update care plans for each resident identified as at risk for falls accordingly. Care plans were to include interventions consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. […]

• No harm, potential for more than minimal, widespreadF755Mar 27, 2026

  Based on facility policy review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on six of six medication carts. (Unit I Carts 1, 2, 3 and Unit II Carts 1, 2, 3)Findings include: Review of the facility policy entitled, Controlled Substance Administration and Accountability, last reviewed February 26, 2026, revealed that two licensed nurses were to account for all controlled substances at the end of each shift for areas without automated dispensing systems. […]

• No harm, potential for more than minimal, widespreadF812Mar 15, 2024

  Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during a tour of the kitchen on March 12, 2024, at 9:47 a.m., revealed the following: The inside of the microwave was dirty and splattered with dried food. In the food preparation area, there were two uncovered garbage cans that contained garbage. There was a dirty plastic bag that covered tubing for the juice machine. There was an accumulation of dirt and grease on the side of the grill, underneath the flat top, and surrounding the stove top controls. There was a puddle of water under the steamer. There was debris under the shelves in dry storage. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2022

  Based on observation, staff interview, and review of facility records it was determined that the facility failed to store food under sanitary conditions in the kitchen and on two of two nursing units. (Units one and two) Findings include: Observation of the kitchen on April 12, 2022, at 10:22 a.m., revealed a bag of potatoes stored on the same shelf as raw meat in the walk in refrigerator, and a bag of shredded lettuce with a best by date of March 22, 2022. There was a reddish brown substance on the deflector in the ice machine. In an interview during the observation, the regional director of food service stated the facility maintenance department is responsible for cleaning the inside of the ice machine in the kitchen. […]