Willowbrooke Court-Southampton

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 5, 2021

  Based on facility policy review, observation, staff interview, facility documentation review, and clinical record review, it was determined that the facility failed to provide an environment and adequate supervision to prevent accidents related to elopement (unauthorized departure from the facility), resulting in actual harm and death for one of four sampled residents. This failure resulted in an Immediate Jeopardy situation (Resident CL1). Findings include: Review of the facility policy entitled, Skilled Nursing Admission Staff Assignment, written March 4, 2021, noted, Prior to or upon admission of a resident to Willowbrooke Court, the Nursing Supervisor will assign the new resident to a nurse and a certified nursing assistant immediately. […]

• No harm, potential for more than minimal, patternF921Mar 23, 2023

  Based on observation and staff interview, it was determined that the facility failed to provide maintenance services to ensure safe water temperatures on one of two nursing units. (Willowbrooke Court) Findings include: Observation on March 22, 2023, at 10:00 a.m., on the Willowbrooke Court nursing unit revealed the following elevated water temperatures in areas accessible to residents: Public restroom across from the Administrator's office: 118.9 degrees Fahrenheit ( F). Resident room [ROOM NUMBER] bathroom sink: 120.2 F. Resident shower room sink (spa): 120.3 F. Willow dining room sink: 120.2 F. Resident room [ROOM NUMBER] bathroom sink: 115.8 F. Willow Gardens laundry room sink: 116.4 F. […]

• No harm, potential for more than minimal, patternF812Apr 1, 2022

  Based on facility policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner during tray line service in one of two dining rooms. (Willowbrooke Court Dining Room) Findings include: Review of the policy entitled, Single Use Glove Usage, dated January 26, 2022, revealed that gloves should only be used for one task, such as ready to eat foods, and then discarded. Observation of tray line service on March 30, 2022, at 12:05 p.m. in the Willowbrooke Court Dining Room revealed the Nutrition Services Manager serving unwrapped food from the steam table, leaving the service line to rinse a knife in the sink, returning to the tray line, and serving unwrapped food without changing her gloves. […]

• No harm, potential for more than minimal, patternF812Jul 22, 2021

  Based on observation, facility policy review, and staff interview, it was determined the facility failed to ensure that refrigerators in common areas were properly maintained on two of four nursing units. (Willowbrooke Court Team one and WillowBrooke Court Team two) Findings include: Review of facility policy entitled, Common Area Refrigerator Maintenance, dated February 9, 2021, revealed refrigerators in common areas were to remain clean at all times. There should be no items that have reached their expiration date. If any item was opened it was to be dated with an expiration date. Liquids should be discarded seven days after opened and foods should be discarded three days after opened. The 11:00 p.m.to 7:00 a.m. […]

• No harm, potential for more than minimal, isolatedF689Apr 1, 2022

  Based on clinical record review and a review of incident reports, it was determined that the facility failed to implement recommended fall interventions for one of six sampled residents at risk for falls. (Resident 73) Findings include: Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], and had diagnoses that included dementia, history of falling, and rhabdomyolysis (breakdown of skeletal muscle due to muscle injury). Review of the Minimum Data Set assessment, dated March 14, 2022, revealed the resident was cognitively impaired and required extensive assistance from staff for bed mobility and toileting. […]