Willowbrook Healthcare

In the surveyor’s words

From the most serious findings on record at Willowbrook Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF604May 28, 2026

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from physical restraints, failed to have documented evidence of assessments for the restraints, and failed to document ongoing re-evaluation of the need for the restraints when the use of restraints was indicated, for 3 of 3 sampled residents, Resident (R) 10, R38, and R41. Observations of R10, R38, and R41 on 05/26/2026 and 05/27/2026 revealed the residents sitting in their motorized wheelchairs with a restraint device on the residents.The findings include:Review of the facility's policy titled, Use of Restraints, revised December 2007, revealed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives… […]

• No harm, potential for more than minimal, patternF761May 28, 2026

  Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the American Diabetic Association's (ADA) document, review of manufacturer's guidelines, and review of the facility's policy, the facility failed to ensure all medications were stored in a manner that protected them from temperature changes, humidity changes, and exposure to light for 1 of 2 medication rooms, the North Hall medication room. The findings include: Review of the facility's policy titled, Storage of Medications, revised 04/2007, revealed nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. […]

• No harm, potential for more than minimal, isolatedF628May 28, 2026

  Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative(s) of the transfer to the emergency department and the reasons for the move in writing and in a language and manner they understood and provide written information to the resident or resident representative of the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility for 2 of 3 sampled residents, Resident (R) 6 and R7. On 4/30/2026, R7 was sent to the local emergency room due to her having an unwitnessed fall in the bathroom. R7 did not receive a bed hold/transfer notice prior to being sent out from the facility. […]

• No harm, potential for more than minimal, isolatedF641May 28, 2026

  Based on interview, record review, and review of the facility's job description, the facility failed to ensure Minimum Data Set [MDS] assessments accurately reflected the residents' status for 3 of 17 sampled residents, Resident (R) 10, R38, and R41 for physical restraints. Refer to F604The findings include: Review of the facility's job description MDS Coordinator revealed the duties and responsibilities included scheduling, completing, and submitting MDS assessments in accordance with the Resident Assessment Instrument (RAI) Manual, and state and federal regulations. Review of the facility provided MDS, dated [DATE] at 10:57 AM revealed it did not have R10, R38, and R41 coded for physical restraints. […]

• No harm, potential for more than minimal, isolatedF656May 28, 2026

  Based on observation, interview, record review, review of a facility job description, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 35 sampled residents, Resident (R) 41. […]