Willowbrooke Court SC Ctr at Matthews Glen

In the surveyor’s words

From the most serious findings on record at Willowbrooke Court SC Ctr at Matthews Glen, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 8, 2025

  Based on observations and staff interviews, the facility failed to discard expired food and milk available for use in 1 of 2 walk-in refrigerators (produce refrigerator) in the main kitchen and 1 of 2 nourishment refrigerators. This practice had the potential to affect the food served to residents. The findings included: 1. During the initial tour of the main kitchen on 7/7/25 from 10:20 AM to 10:45 AM with the Lead Chef, an observation of the walk-in produce refrigerator revealed a box of red and green bell peppers. There were four red bell peppers and three green bell peppers inside the box. Three of the four red bell peppers were covered with gray and white fuzz. There was no date on the box. The Lead Chef went through the box and discarded three of the red bell peppers that had fuzz. […]

• No harm, potential for more than minimal, patternF812Mar 2, 2022

  Based on observations and staff interviews, staff failed to change gloves and sanitize hands between handling soiled and clean dishware for 1 of 1 dietary aide (Dietary Aide #1). This practice had the potential to cross-contaminate food served to residents on the Red Oak dining hall. The findings included: During a continuous observation on 3/1/22 from 9:15 AM to 9:32 AM, a tour of the satellite kitchen on the Red Oak dining hall, Dietary Aide (DA) #1 was observed wearing gloves when handling a dish cart with soiled dishware (3 coffee cups, 4 dessert or fruit bowls, 14 pieces of silverware including knives, forks, and spoons). DA #1 was observed pushing the soiled dish cart towards the dish machine area in the satellite kitchen. […]

• No harm, potential for more than minimal, isolatedF684Jul 8, 2025

  Based on observations, record reviews and interviews with the resident, staff and Medical Doctor (MD), the facility failed to ensure treatment for a non-pressure related area of skin impairment was completed daily per the standing order for 1 of 1 sampled resident (Resident #5) reviewed for skin conditions. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and Parkinsonism (brain condition that cause slowed movements, stiffness and tremors). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. […]

• No harm, potential for more than minimal, isolatedF759May 30, 2024

  Based on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 25 opportunities which resulted in an 12% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident #57). Findings included: 1a. A Physician's order dated 5/21/24 read Ceftriaxone sodium (antibiotic) intravenous solution reconstituted 2 grams (gm), use 2 gm intravenously (IV) in the morning for sepsis until 6/27/24. […]

• No harm, potential for more than minimal, isolatedF761May 30, 2024

  Based on observations, record review, and staff and resident interviews the facility failed to store a medication and left it unattended at the bedside for 1 of 1 resident (Resident #5) reviewed for medication storage. The findings included: Resident #5 was admitted to facility on 5/9/24 with diagnosis that included constipation. A review of the Resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. A review of Resident #5's physician order dated 5/25/2024 revealed he was ordered Senna S Oral Tablet 8.6-50 milligrams (MG). […]