Willowbrook Rehabilitation and Care

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF658Sep 12, 2025

  Based on record review, and staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #76) attended his doctor appointment when Resident #76 missed a scheduled orthopedic appointment on 9/12/24 to have stitches removed due to facility failure to transcribe the order resulting in a missed doctor appointment. The findings included:Resident #76 was admitted to the facility on [DATE] with diagnosis including displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and anxiety.Resident # was discharged from the facility on 9/20/24. During an interview with Unit Manager #1 on 9/11/25 at 12:03 p.m. she revealed that Resident #76 missed his appointment to have his stiches removed on 9/12/24. […]

• No harm, potential for more than minimal, isolatedF759Sep 12, 2025

  Based on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 31 medication administration opportunities resulting in a medication error rate 6.45% for 2 of 6 residents observed during medication pass (Resident #3 and Resident #41).The findings included:1.Resident #3 was admitted to the facility on [DATE] with diagnoses that included glaucoma.A review of Resident #3's active physician orders dated 7/3/25 included a current order for Dorzolamide HCL-Timolol Maleate Ophthalmic Solution 2-0.5% (a combination medication used to lower intraocular pressure in patients with open-angle glaucoma) one (1) drop to right eye twice a day. […]

• No harm, potential for more than minimal, isolatedF656Aug 2, 2023

  Based on resident and staff interviews and record review, the facility failed to develop a care plan that addressed discharge goals and plans for 2 of 17 residents (Residents #1 and #55) reviewed for comprehensive care plans. Findings included: 1. Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed an active discharge plan was in place for the resident to return to the community. The quarterly MDS assessment dated [DATE] indicated Resident #1 was cognitively intact. The comprehensive care plan, updated 7/14/23, did not include information that addressed discharge plans or goals. In an interview with Resident #1 on 8/1/23 at 2:36 PM, he shared his discharge plan was to remain in the facility for long term care. […]

• No harm, potential for more than minimal, isolatedF761Aug 2, 2023

  Based on observations and staff interviews, the facility failed to secure medicated treatments left in an unattended treatment cart for 1 of 1 treatment cart. The findings included: During wound care observation on 8/1/23 at 10:53 AM, Nurse #1 was observed to push the treatment cart against the wall on the 200 hall and entered a resident room and closed the door to perform wound care. The cart lock was not pushed in indicating a locked position. Observation of Treatment Cart #1 revealed the top drawer to contain topical ointments. The second drawer contained medicated dressings and bandages. […]

• No harm, potential for minimal, patternF623Aug 2, 2023

  Based on resident and staff interviews, interview with the Ombudsman and record reviews, the facility failed to provide the resident a written notification for the reason for transfer to the hospital and failed to provide a copy of the transfer/discharge notice to the Ombudsman for 2 of 4 residents (Resident #56 and Resident #58) reviewed for hospitalization . Findings included: 1. Resident #56 was admitted to the facility on [DATE]. He was listed in the electronic health record as his own responsible party. The medical record demonstrated the resident was transferred to the hospital on 6/28/23 due to a change in condition. Resident #56 returned to the facility on [DATE]. […]