Willowbrooke Court at Country House

In the surveyor’s words

From the most serious findings on record at Willowbrooke Court at Country House, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 9, 2024

  Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings include: 2/5/24 from 8:22 AM to 8:35 AM, observation of the kitchen with E1 (NHA) revealed the following: - observed 1/4 tray of cake (vanilla with chocolate icing) and a full tray of sloppy joe were undated in the refrigerator; - observed a full tray of frozen dough that was not covered completely and undated, a plate with two pieces of cooked chicken was uncovered and undated and a clear bag of chicken nuggets was undated in the walk-in freezer. […]

• No harm, potential for more than minimal, patternF842Feb 9, 2024

  Based on record review and interview it was determined that for one (R4) out of five residents reviewed for clinical records, the facility failed to ensure that R4's medical records were complete and readily accessible as evidenced by the failure to upload the attending physician notes in the EMR (electronic medical record). Findings include: 5/21/20 - R4 was admitted to the facility. 1/23/23 - R4 was seen by E6 (MD) for R4's required 60 day visit. 3/27/23 - R4 was seen by E6 for R4's required 60 day visit. 5/6/23 - R4 was seen by E6 for R4's required 60 day visit. 6/26/23 - R4 was seen by E6 for R4's required 60 day visit. […]

• No harm, potential for more than minimal, isolatedF623Feb 26, 2025

  Based on clinical record review and interview, it was determined that for one (R3) out of one resident reviewed for hospitalization, the facility failed to send a copy of a hospital transfer notice to the Office of the State Long-Term Care Ombudsman. Findings include: Review of R3's clinical record revealed: 1/10/25 - R3 was admitted to the facility with multiple diagnoses, including the aftereffects from a fall, heart disease, chronic pain, diabetes and anemia. 1/15/25 - R3 experienced severe stomach pain with diarrhea, and the R3 was sent to the hospital for an evaluation, and was admitted to the hospital. […]

• No harm, potential for more than minimal, isolatedF684Feb 26, 2025

  Based on interview and record review, it was determined that for one (R1) out of five residents reviewed for unnecessary medications, the facility failed to ensure that R1's physician order for weekly blood pressure (BP) monitoring on Mondays was completed. Findings include: Review of R1's clinical record revealed: 5/22/24 - R1 had a physician's order for blood pressure every week on Mondays for diagnosis of high blood pressure. According to the monthly electronic MARs, R1 was receiving the following medications for a diagnosis of high blood pressure from December 1, 2024 through February 18, 2025: - Cardizem daily; - Hydrochlorothiazide daily; and - Atenolol twice a day. […]

• No harm, potential for more than minimal, isolatedF712Feb 9, 2024

  Based on record review and interview, it was determined that for one (R8) out of five residents reviewed for physician services, the facility failed to ensure the resident was seen for the required physician visits. Findings include: R8's clinicial record revealed: 12/5/23 - R8 was admitted to the facility. Review of R8's clinical record revealed the absence of an initial comprehensive visit by the Physician. 2/8/24 at 2:03 PM - During a combined interview, finding was confirmed with E1 (NHA) and E3 (Regional Clinical Director). 2/9/24 at 3:30 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).