Willowbrooke Ct Skilled Care CTR at Bayleigh Chase

In the surveyor’s words

From the most serious findings on record at Willowbrooke Ct Skilled Care CTR at Bayleigh Chase, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 17, 2025

  Based on facility reported incidents, record review and interview with facility staff it was determined that the facility staff failed to protect residents against incidents of abuse, and ensure measures were put in place to prevent further incidents of abuse. This was evident for 3 (#905, #901, and #45) of 9 residents reviewed for abuse. The facility was notified of the immediate jeopardy at 4:40 PM on 1/13/25. The facility developed a plan to sufficiently remove immediacy, which was reviewed and accepted after 3 attempts, at 6:37 PM on 1/13/2025 while surveyors remained onsite. The plan to remove immediacy that was presented to surveyors included: Resident #905 passed on 8/2/23, Resident #901 passed on 2/22/23. […]

• Actual harm, isolatedF689Jan 17, 2025

  Based on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R)52) of two residents reviewed for falls out of a total sample of 27 residents had root cause analysis and a thorough investigation completed to determine if additional interventions were warranted when the resident had 11 falls, one resulting in harm when the resident sustained a left hip fracture requiring surgery. This had the potential for the resident to continue to have falls with possible major injuries. […]

• No harm, potential for more than minimal, widespreadF730Jan 17, 2025

  Based on review of staff records and interview with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months. This was evident for all GNA's working in the facility since 2022 and has the potential to affect all residents. Failure to perform performance reviews prevents the facility from providing regular in-service education that is based on the outcome of these reviews. The evidence includes: The employee file of GNA#7 was reviewed on 1/13/25 at 9:30 AM, during review of a facility reported incident (#MD00182604) related to abuse. No performance reviews were found in the file. […]

• No harm, potential for more than minimal, widespreadF812Jan 17, 2025

  Based on observation, record review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential to affect all residents of the facility who consumed food from the kitchen, with the exception of one resident who was nothing by mouth (NPO). Findings include: Review of the food temperature logs provided by the Dietary Manager (DM) revealed for the time period from 01/01/25 until 01/09/25 revealed temperatures were not documented for all three meals or all the hot food items prepared for each meal. […]

• No harm, potential for more than minimal, widespreadF867Jan 17, 2025

  Based on interview and review of facility documentation, the Quality Assurance (QA) committee failed to complete a thorough Performance Improvement Project (PIP) that was a continuous improvement of processes, measured outcomes, develop, and implemented action plans, measured success, and contained a root cause analysis. This failure had the potential to affect all 55 residents in the facility by not identifying problems that impact their quality of life, quality of care, and resident safety. […]