Willowbrooke Court Skilled Care Center at Mease Li

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 18, 2022

  Based on observation, interview, and record review, the facility neglected to assess a newly admitted resident (Resident #198) for his potential for wandering which could have prevented the resident from leaving the facility unsupervised and suffering scrapes, bruises and requiring a visit to the emergency room . Findings included: Resident #198 was admitted to the facility on [DATE] at 10:45 p.m., with diagnosis to include dementia, depression, anxiety, [CONDITION(S)], history of falling, weakness, muscle weakness and difficulty in walking. An interview was conducted on 8/16/22 at 8:34 a.m. with Staff A, Licensed Practical Nurse (LPN). Staff A stated she was notified by the day nurse upon arrival on her shift at 7:00 p.m. that she would have an admission. […]

• No harm, potential for more than minimal, patternF623Apr 2, 2021

  Based on record reviews and interviews, the facility failed to ensure the representative of one (Resident #17) of two residents sampled for hospitalization s received a written notice of transfer and that the Office of the State Long-Term Care Ombudsman received copies of the facility-initiated transfer or discharge notice for residents with an unplanned transfer. Findings included: Resident #17 was originally admitted to the facility on [DATE] with a recent admitted [DATE]. The Profile Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF732Aug 18, 2022

  Based on observations, record reviews, and interviews, the facility failed to accurately post the required daily staffing information. Findings included: On 08/15/2022 at 9:02 a.m., upon entry into the facility, an observation of the bulletin board located on the 1st floor next to the Nurse's station, revealed there was no current Daily Staffing Sheet, a document that provided information of the number of residents and the total hours of nursing staff working all on three shifts for that day. On 08/15/2022 at 3:13 p.m., an observation revealed no Daily Staffing Sheet posted for the current day. On 08/16/2022 at 7:35 a.m., while touring the 1st floor nursing unit, an observation revealed no Daily Staffing Sheet posted for the day. […]

• No harm, potential for more than minimal, isolatedF625Apr 2, 2021

  Based on record reviews and interviews the facility failed to ensure that the representative of one (Resident #17) of two residents sampled for hospitalization s was notified of the bed-hold policy. Findings included: Clinical record review revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Profile Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated the resident had a Power of Attorney (POA) and the payor source was Hospice Medicaid. The Quarterly Minimum Data Set (MDS), completed 10/6/2020, indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF676Apr 2, 2021

  Based on observation, interview, and record review the facility failed to ensure that dignity was maintained related to activities of daily living (ADL) care for removal of facial hair for one (Resident #194) out of 12 sampled residents. Findings included: Multiple observations were made of Resident #194, including on 3/31/21 at 10:30 a.m. and 04/01/21 at 10:45 a.m. During every observation, gray facial hairs approximately 1/4 inch in length were observed covering the resident's chin. On 04/01/21 at 10:45 a.m. the resident was asked whether she preferred to have the facial hair on her chin and she said, I don't like hair on my face, and reported that when she had been living at home home she removed it. The resident reported that nobody in the facility had asked her about it. […]