Willowbrooke Court Skilled Care at Evergreens

In the surveyor’s words

From the most serious findings on record at Willowbrooke Court Skilled Care at Evergreens, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 3, 2025

  Repeat Deficiency Based on observations, interviews, and review of facility documents, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store foods in a safe and sanitary environment to prevent the development of food borne illness.This deficient practice was observed during the tour of two kitchens and was evidenced by the following:On 08/28/2025 9:30 AM, the surveyor toured the Country Kitchen which served the second-floor residents with the Director of Culinary Services (DCS) in the presence of a second surveyor.The surveyor observed a Dietary Aide (DA) coming out of the rear kitchen area without a hair restraint for a lengthy think dark beard. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 06/05/24 from 8:56 AM to 9:25 AM, the surveyor, accompanied by the Regional Culinary Director (RCD) observed the following in the kitchen: 1.) The RCD washed her hands at a designated hand washing sink for 12 seconds. 2.) The step can style trash can at the employee hand washing sink had small flying insects (identified by the RCD as fruit flies) flying inside and outside of the trash can when opened. […]

• No harm, potential for more than minimal, patternF812Oct 27, 2022

  Based on observation and interview, the facility failed to ensure foods stored in dry storage were resealed closed when opened. This failure had the potential to affect the 12 residents who ate food prepared by the kitchen. Findings include: The following observations in the kitchen were made with and verified by the Director of Culinary and Nutrition Services (DCN). On 10/24/22 at 10:30 AM, observation of the dry storage room revealed one box of thickener, one bag of dried cranberries, one bag of cake mix, one container of fried onion sticks, one bag of raisins, and one container of chopped nuts, that were open to air. During an interview on 10/24/22 at 10:43 AM, DCN stated, The food items should be sealed closed after opened. […]

• No harm, potential for more than minimal, isolatedF610Jun 7, 2024

  Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) identify and investigate a bruise of unknown origin and b.) follow interventions implemented on the Care Plan (CP) for a resident identified as having fragile skin. This deficient practice was identified for 1 (one) of 2 (two) residents (Resident #117) reviewed for accidents and was evidenced by the following: The Admission Record dated 06/06/24, indicated that Resident #117 had diagnoses which included, but were not limited to, dementia and major depressive disorder. […]

• No harm, potential for more than minimal, isolatedF578Oct 27, 2022

  Based on record review, staff interview, and review of facility policy, the facility failed to ensure the right to formulate advance directives by failing to ensure a current copy of each resident's advance directive was in the resident's medical record for two of three residents (Resident (R) 6 and R7) reviewed for advance directives. Findings include: 1. Review of R7's profile located on the ''Profile'' tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE]. Review of the ''Misc'' (miscellaneous) tab in EMR revealed a notarized durable power of attorney dated 09/10/01 and signed by R7. […]