Willowbrooke Court Skilled Center at Manor House

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 5, 2021

  Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for one (R9) out of two sampled residents reviewed for accidents, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible. For R9, an unsafe transfer was performed using a Sit-to-Stand mechanical lift with only one CNA as opposed to a Hoyer Lift (full body mechanical lift) with two CNA's per R9's plan of care, resulting in a fracture of R9's left leg. The unsafe transfer caused R9 harm. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2026

  Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. 6/3/26 10:22 AM - During a tour of the kitchen, a heavy build up of dust clumps was present on the wall adjacent to a food prep table and the ice machine. The air filters of the ice machine were covered in a thick layer of dust. 6/3/26 10:24 AM - Findings were reviewd with E5 (DOC/N) during the kitchen tour. 6/5/26 12:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

• No harm, potential for more than minimal, patternF812Nov 5, 2021

  Based on observation and interview, it was determined that the facility failed to ensure safe and sanitary storage of food in one out of two unit nourishment refrigerators. Findings include: During numerous tours of the two nutrition rooms throughout the day on 11/1/21, the surveyor observed the following: 11/1/21 10:26 AM - The unit refrigerator in the nutrition room on the Lewes Short hall had five (5) undated, unlabeled black plastic food containers and a white plastic bag containing two (2) additional undated, unlabeled black plastic food containers identified by E7 (Nutritional Service Manager) as food brought in by family members for a specific resident. […]

• No harm, potential for more than minimal, patternF842Nov 5, 2021

  Based on record review and interview it was determined that, for six (R2, R3, R11, R22, R25 and R31) out of six residents investigated for unnecessary medication review, the facility failed to ensure records were accurate and complete. Findings include: 1. 11/2/21 at approximately 12:40 PM - During an interview with E1 (NHA), the Surveyor requested copies of the monthly pharmacy review reports for the previous twelve months for the five residents (R2, R3, R11, R22 and R25) selected for unnecessary medication review. 11/3/21 at approximately 10:30 AM - During an interview, E2 (DON) informed the Surveyors that they (the facility) were trying to locate all of the information requested for drug reviews since they were not in one location. […]

• No harm, potential for more than minimal, patternF880Nov 5, 2021

  Based on observation, interview, and record review it was determined that the facility failed to provide appropriate infection surveillance for one resident (R11) out of two residents reviewed for constipation and diarrhea. The facility failed to isolate R11 when the resident continued to have symptoms of [CONDITION(S)] Infection (infectious loose stools). Additionally, the facility failed to follow the core principles of COVID-19 infection prevention for staff use of PPE (personal protective equipment) in the kitchen area. Findings include: According to the Centers for Disease Control (https://www.cdc.gov/cdiff/clinicians/faq.html): Isolation for C-Diff should continue until loose stools cease. […]