Willowbrook Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 7, 2023

  Based on interview and record review it was determined the facility failed to ensure residents were free from mental, verbal and physical abuse and intimidation for 3 of 3 residents (#s 1, 2 and 3) reviewed for abuse. This failure resulted in Resident 2's right to refuse care not being honored, resulting in mental anguish as evidenced by physically forcing care upon and mocking Resident 2. Additionally, this placed all residents at risk for abuse and intimidation. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. […]

• Immediate jeopardy, isolatedF609Dec 7, 2023

  Based on interview and record review it was determined the facility failed to report allegations of abuse for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse. This failure to report past abuse allegations resulted in Resident 2's physical, verbal and mental abuse and placed all residents at increased risk of abuse and intimidation. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. The 12/7/23 Written Statements of Staff 5 (CNA) and Staff 6 (CNA) revealed allegations that Staff 3 (RN) abused Resident 1. There was no evidence a FRI (Facility Reported Incident) was sent in to the State Agency. […]

• Immediate jeopardy, isolatedF658Dec 7, 2023

  Based on interview and record review it was determined Staff 3 (RN) failed to provide care and services which allowed residents the right to refuse care and physically forced personal care upon 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse and nine unsampled residents, which did not meet professional standards of quality. This failure resulted in widespread refusal of care not being honored by Staff 3, provision of care against residents' wishes, mental anguish due to intimidation, mocking of Resident 2, potential of further vilation of resident rights, and care being forced upon all residents. Findings include: 1a. […]

• Actual harm, isolatedF688May 17, 2024

  Based on observation, interview and record review it was determined the facility failed to prevent loss of range of motion and development of contractures for 1 of 1 sampled resident (#23) reviewed for contractures. This failure resulted in Resident 23 developing bilateral (both) hand contractures and experiencing significant pain in her/his hands. Findings include: The facility's 2/2018 Restorative Nursing Policy and Procedure revealed the following: -Based on a comprehensive assessment of the resident's current functional status related to communication, mobility, range of motion, performance of ADLs, eating and toileting, the RCM (Resident Care Manager) will determine appropriateness for participation in restorative nursing programs. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2025

  Based on observation, interview and record review it was determined the facility failed to store and handle food in a sanitary manner in 1 of 1 kitchen and 2 of 2 snack refrigerators. This placed residents at risk for food borne illness. Findings include:The facility's Personal Hygiene, Food Handling and Storage Policy dated 8/2024 revealed the following:- Individuals handling food must practice good personal hygiene to minimize the risk of contaminating food and causing foodborne illness. Food storage areas shall be maintained in a clean, safe, and sanitary manner.- Hairnets, hats, or coverings are required at all times, [including] beard guards/masks for facial hair longer than trimmed eyebrows. […]