Willowbrooke Court at St Andrews Estates

In the surveyor’s words

From the most serious findings on record at Willowbrooke Court at St Andrews Estates, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 1, 2025

  Based on observations, interviews, and policy review, the facility failed to follow standards of professional practice for food safety, as evidenced by raw chicken and Mighty Shakes were stored in the refrigerator past the recommended time frames for food safety. This had the potential to affect 42 of 44 residents on oral diets. The findings included: Review of the facility's policy included a Food Storage Chart by HACCP, last revised in October 2014. It said that raw meat can be stored in the refrigerator for 4 days (including the day of delivery). Review of the United States Food and Drug Administration's (USFDA) Refrigerator and Freezer Storage chart dated March 2018, stated that uncooked chicken can be stored in the refrigerator for 1-2 days. […]

• No harm, potential for more than minimal, isolatedF693May 1, 2025

  Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 sampled resident reviewed for tube feeding, Resident #43. The findings included: Review of the facility's policy, titled, Tube Feeding and Medication Administration, with a revised date of 06/2018, included in part the following: Check for placement of the nasogastric, Dobhoff, gastric or PEG tube before every feeding or administration of medication to be sure it hasn't slipped out of the resident's stomach. Note: Never give tube feeding until proper positioning of the tube is determined. […]

• No harm, potential for more than minimal, isolatedF726May 1, 2025

  Based on observations, interviews, and record review, the facility failed to ensure all nursing staff professional standard of quality for 1 of 24 nurses employed by the facility observed during 1 of 4 medication administration observations, to ensure the correct process was followed. The findings included: Review of the facility's policy titled, Orientation for Professional Staff, dated 08/2021, included the following: To strive to assure that all nurses possess the competencies and skill sets necessary to provide nursing and related services to meet the residents'' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial wellbeing. Procedure: 1. […]

• No harm, potential for more than minimal, isolatedF755May 1, 2025

  Based on record review, interview and observation, the facility failed to maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 5 sampled residents reviewed for controlled medications, Resident #4. The findings included: Review of the facility's policy titled, Medication, Controlled Substances, with a revised date of 04/2024, included in part the following: To strive to ensure that strict management of controlled substances is maintained as evidence by special handling, storage , disposal and record keeping. […]

• No harm, potential for more than minimal, isolatedF757May 1, 2025

  Based on observations, interviews, and record review, the facility failed to monitor behaviors as per physician's orders for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #7 and Resident #23. The findings included: Review of the facility's policy, titled, Psychotropic Medications, dated 03/2025, included the following: 3. The community supports the goal of determining the underlying cause of behavioral symptoms so that appropriate treatment of the environment, medical, and/or behavioral interventions, as well as psychotropic medications, (if clinically necessary), can be used to meet the needs of the individual resident. Procedure: 1. […]