Willowbrook Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 5, 2021

  This Citation pertains to Intake Number MI 228. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for 1) Its failure to assess, monitor and change a dressing, that was saturated with drainage from a surgical wound, on the upper left chest and a surgical wound on the left lower leg and 2) Its failure to apply a wound vac to the surgical wound on the left lower leg as ordered for one resident (Resident #1) of six residents reviewed for wound care. This deficient practice increased the likelihood of infection causing serious harm (sepsis, shock, organ failure), serious injury (loss of a limb) and/or death. […]

• Actual harm, isolatedF686Aug 12, 2026

  This citation pertains to intake Number 3050939. Based on observation, interview and record review, the facility failed to provide the necessary treatment consistent with professional standards of practice to prevent the development of and/or promote the healing of pressure ulcers for four residents (Resident #1, Resident #112, Resident #114, Resident #115) of six residents reviewed for pressure ulcers, resulting in the development of facility-acquired pressure ulcers. Findings include: Resident #1 (R1): R1 is [AGE] years old and initially admitted to the facility on [DATE] with diagnoses that include nontraumatic intracerebral hemorrhage, compression of the brain, Glasgow coma scale score of 3-8 (indicating a severe traumatic brain injury) and tracheostomy status. […]

• Actual harm, isolatedF686May 23, 2024

  This Citation pertains to intake MI00138800. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management for two residents (Resident #704 and Resident #710) of two residents reviewed, resulting in a lack of implementation and documentation of meaningful, resident-centered interventions for pressure ulcer prevention, the development and worsening of facility-acquired pressure ulcers, unnecessary pain, and the likelihood for a decline in overall heath status. […]

• Actual harm, isolatedF684Dec 20, 2023

  This Citation pertains to Intake Number MI00141163. Based on observation, interview and record review the facility failed to 1) Monitor blood glucose levels and signs/symptoms of diabetic complications; 2) Recognize a change of condition in a timely manner; 3) Document clinical assessment of a resident during a change in condition and the subsequent measures taken; and 4) Provide documented clinical interventions, care plans and coordination for consistent refusal of all medications since readmission for one resident (Resident #902). […]

• Actual harm, isolatedF686Jun 16, 2023

  Based on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcers for 2 residents (Resident #42 and Resident #72) and ensure that residents were assessed, monitored, wound care was provided as ordered and appropriate interventions were in place for 3 residents (Resident #42, Resident #72 and Resident #262) of 5 residents reviewed for pressure ulcers, resulting in Resident #42 developing a Stage 2 sacral pressure ulcer, Resident #72 developing multiple Stage 2 pressure ulcers to the sacrum and right trochante,; and Resident #262 developing a sacral pressure ulcer that worsened to a Stage 4. […]