Willowbrook Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 19, 2025

  Based on interviews and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (Resident #1) residents reviewed for supervision. The facility failed to notify the transport staff Resident #1 resided on the secure unit and had a diagnosis of dementia. The facility failed to ensure adequate supervision was provided during transport for Resident #1 who resided on the secure unit. On 2/19/25 Resident #1 was left unattended in the transport van for approximately 15 minutes in which Resident #1 eloped out of the van and walked down the road 2 blocks and was picked up by a good Samaritan. […]

• No harm, potential for more than minimal, widespreadF908Apr 7, 2021

  Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen. The facility did not ensure the stove was in working order. Two of six stove burners on the stove did not light. This failure could place the residents at risk of not having safe operating equipment. Findings included: During an observation on 04/05/21 at 9:45 a.m. in the kitchen, two of six stove burners did not light automatically. Cook A was fanning and blowing on the burners to get them to light. During an interview on 04/05/21 at 9:48 a.m., the dietary manager said the burners should light when the knobs were turned on. […]

• No harm, potential for more than minimal, patternF550Jul 9, 2025

  Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 15 residents (Residents #13, #56, and #2) reviewed for resident rights. 1. The facility failed to ensure Resident # 13, and Resident #56 were served breakfast in the dining room in a dignified manner on 7/08/2025.2. The facility failed to ensure CNA K did not stand over Resident # 2 while feeding her on 7/7/25.This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.Findings included:1.Record review of a facility face sheet dated 7/09/2025 revealed Resident #13 was a [AGE] year old female that admitted to… […]

• No harm, potential for more than minimal, patternF880Jul 9, 2025

  Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #2, #20 and #16) and 4 of 5 staff (CNA A, CNA G, CNA K and CNA F) reviewed for infection control. 1. The facility failed to ensure CNA A properly changed gloves and cleaned her hands during incontinent care for Resident #20 on 7/08/2025.2. The facility failed to ensure CNA G performed hand hygiene between passing of resident #16's tray on hall 500 on 7/8/25.3. […]

• No harm, potential for more than minimal, patternF584Jun 19, 2024

  Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 (Residents #30, #71, #43) of 16 resident rooms reviewed for environmental conditions in that: The facility failed to ensure Resident #30's resident restroom did not have dark colored splatters on wall next to toilet and strong odor of urine. The facility failed to ensure Resident #71's resident room did not have crumbs in windowsill and splatters on wall. The facility failed to ensure Resident #43's divider curtain was clean and free of splatters and stains. This deficient practice could place residents at risk of living in an unsanitary environment. […]