Willowbrooke Ctskdcarectr at Fortwashingtonestates

In the surveyor’s words

From the most serious findings on record at Willowbrooke Ctskdcarectr at Fortwashingtonestates, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 18, 2022

  Based on observation, interviews with a resident and staff, review of clinical records, review of facility documentation, and review of facility policies and procedures, it was determined that the facility failed to ensure that each resident's environment remained free of accident hazards by failing to test the temperature of hot coffee prior to being served to residents. This failure resulted in an Immediate Jeopardy situation to Resident R1 who spilled hot coffee on the left upper thigh and developed a second degree burn for one of two residents reviewed. (Resident R1). […]

• Immediate jeopardy, isolatedF689Sep 22, 2022

  Based on review of clinical records, staff interview and facility documentation, it was determined that the facility failed to implement safety measures to prevent accidents for one of 12 residents reviewed.(Resident R24) This failure resulted in actual harm to Resident R24 who sustained a fall from bed, required transfer to the hospital and a diagnosis of a right parietal scalp hematoma. (Resident R24) Findings include: Review of Resident R24's clinical record revealed the resident was admitted to the facility on September 13, 2018, with diagnoses of Alzheimer's Disease (progressive [CONDITION(S)] disease of the brain), [CONDITION(S)] (improper functioning of the vein valves in the leg, causing swelling and skin changes) Spinal Stenosis (the space inside the backbone is too small causing… […]

• Actual harm, isolatedF600Sep 22, 2022

  Based on review of clinical records, staff interview, review of facility policy and facility documentation, it was determined that the facility failed to ensure one of 12 residents reviewed was free of neglect. (Resident R24). This failure resulted in actual harm to Resident R24 who sustained a fall from bed, required transfer to the hospital and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of facility policy, Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Property Prevention, dated as revised May 2021, defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2022

  Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department conducted on September 19, 2022, at 9:30 a.m. with Employee E6, Food Service Director (FSD), revealed the following: Observation in the main dry storage area revealed multiple boxes, stainless steel stock pots and plastic catering equipment stored on the top shelf less than the required 18 from sprinklers heads and the ceiling. Observation in the main kitchen hot production area revealed two steam kettles, a tilt skillet and the steamer all with the exterior surfaces covered in dark black and brown burned on food spatter stains. […]

• No harm, potential for more than minimal, isolatedF684Feb 27, 2025

  Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that physician orders were followed for one of two residents observed during medication administration. (Resident R111) Findings include: On February 24, 2025, 8:20 a.m., observed that Employee E5, a Registered Nurse, administered to Resident R111, the medicine, Bicalutamide Oral Tablet 50 MG (Bicalutamide), give 50 milligrams by mouth one time a day for prostate cancer related to Malignant Neoplasm of Prostate; but, E5 administered the medicine, Bicalutamide Oral Tablet without wearing gloves when handling Bicalutamide medication and E5 did not wash her hands after. […]