Willowbrooke Court-Granite

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812May 27, 2021

  Based on observations, review of facility policy and procedure, and staff interview it was determined the facility failed to label and date opened containers of food products in the main kitchen. Findings include: A review of the facility policy and procedure titled Date Markings Ready-To-Eat Foods, with a revision date of February 2017, revealed all ready-to-eat foods will be the date marked to strive to ensure appropriate rotation and prevent foodborne illness. All ready-to-eat foods will be labeled to include the following information: product name and date the product was prepared or opened and the date the product should be used. Observations of the main kitchen with the Dietary Director were conducted on May 24, 2021, at 9:05 a.m. […]

• No harm, potential for more than minimal, isolatedF684May 11, 2023

  Based on clinical record review and interviews with staff the facility failed to follow physician orders for one of 24 residents (R1). Findings include: Observations during the initial environmental tour, on May 8, 2023, revealed that Resident R1 was using oxygen provided through a concentrator. The nasal canula was attached to a canister of water dated April 10, 2023. The tubing for the nasal canula was not dated. An interview with the Nursing Home Administrator(NHA) revealed that the canister and tubing is changed monthly per the facility policy. […]

• No harm, potential for more than minimal, isolatedF689May 11, 2023

  Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide appropriate staff supervision resulting in a fall for one of the nine residents reviewed (Resident 161). Findings include: A review of Resident 161's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 5, 2023, revealed resident was cognitively impaired. The same MDS revealed resident required extensive with two people assistance with transferring. Review of the resident's ADL (activities of daily living) care plan revealed an intervention as follows: Transfer-require extensive assistance by two staff to move between surfaces. […]

• No harm, potential for more than minimal, isolatedF755May 11, 2023

  Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a wound treatment medication order was available for one of the 13 residents reviewed (Resident 159). Finding Include: Review of the facility's policy titled Pharmacy Services revealed, that the pharmacy ensures the provision of pharmaceutical services in an accurate, effective, and safe manner. Also, to provide routine and emergency medications and supplies to meet the needs of each resident following state and federal guidelines. Review of Resident 159's physician order sheet revealed an order on May 2, 2023, for A Dakin's solution to sacral wound, wet to dry cover with dressing daily. […]

• No harm, potential for more than minimal, isolatedF580Jun 24, 2022

  Based on clinical record review, staff interview and policy and procedure review it as determined the facility failed to notify the physician of a change in resident's status for one of 24 residents reviewed. (Resident 43) Findings Include: Review of facility policy and procedure titled Physician Notification, revised June 2014, revealed the licensed nurse is responsible for notifying the resident's physician at a minimum when there is: a significant change in the resident's physical, mental or psychosocial status. A need to significantly alter treatment. A decision to transfer or discharge the resident from the community. […]