Willow Brooke Ct Skilled Care CTR at Heron Point

In the surveyor’s words

From the most serious findings on record at Willow Brooke Ct Skilled Care CTR at Heron Point, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 23, 2024

  Based on record reviews and interviews it was determined that the facility failed to ensure a safe environment for a resident diagnosed with a major depressive disorder. This was found to be evident for 1 (Resident #178) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance. The findings include: According to the National Institute of Health depression (also known as major depression, major depressive disorder, or clinical depression) is a common but serious mood disorder. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2025

  Based on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This was found to be evident during the observation of the kitchen during the recertification survey. This practice had the potential to affect all residents consuming food and beverage prepared and provided by the facility's kitchen. The findings include: During the initial tour of the main kitchen conducted on 12/08/2025 at 8:02 AM the Surveyors and Certified Dietary Manager (CDM) observed the following expired food items in the walk-in refrigerator: Black beans opened 12/03/25 expired 12/07/25, Maraschino Cherries opened 12/03/25 expired 12/06/25, Walnut topping opened 11/29/25 expired… […]

• No harm, potential for more than minimal, patternF609Feb 23, 2024

  Based on the facility's documentation review and staff interview, it was determined the facility failed to report allegations of abuse and injury of an unknown source to the local enforcement agency. This was found to be evident for 4 (residents # 7, #13, #181, & #11) out of 5 residents reviewed for abuse. The findings include: A review of the facility reported incident investigations conducted on 02/15/2024 at 11:29 AM revealed Resident #181 reported to the facility that Geriatric Nursing Assistant (GNA) #27 would not let the resident pass by, the resident pushed the GNA and the GNA pushed the resident and the resident fell back onto the floor. […]

• No harm, potential for more than minimal, patternF610Feb 23, 2024

  Based on review of Facility Reported Incidents (FRI) and interview with staff, it was determined that the facility failed to complete a thorough investigation. This was evident for 6 (Resident #3, #4, #5, #21, #7, and #13) out of 13 residents investigated for Facility Reported Incidents. The findings include: Geri sleeves protect the arms and legs from skin tears, abrasions, and light bruising caused by friction and shearing in the bed and wheelchair. On 2/20/2024 at 1:30 PM, the Surveyor reviewed Resident #3's electronic and paper medical record which revealed that on 5/9/2023 at 7:37 PM, Geriatric Nursing Assistant (GNA) #28 reported to a nurse that when she got the resident up from the bed to the chair, she noticed a patch of blood on the resident's upper left sleeve. […]

• No harm, potential for more than minimal, patternF726Feb 23, 2024

  Based on record review and interviews, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 4 out of 5 GNAs (GNA #6, #7, #8, #9, & #10) reviewed for competencies skill evaluations. The findings include: On 02/14/2024 at 8:10 AM, the surveyor reviewed the employee files and was unable to locate skill competency evaluations for Geriatric Nursing Assistants (GNA) #6, #7 #8, #9 & #10. […]