Willowbrooke Ctskdcarectr Atnormandy Farms Estates

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 31, 2024

  Based on observations, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was transferred from bed to chair with the assistance of two staff members. This failure resulted in actual harm to Resident R1 whose left foot twisted under the resident and sustained a trimalleolar fracture of the left ankle. (Resident R1) Findings include: Review of Resident R1's clinical record review revealed that the resident was admitted to the faciltiy on September 17, 2020 with the diagnoses of Alzheimer's Disease (progressive degenerative disease of the brain) and chronic kidney disease, osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone) unsteady… […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2021

  Based on observation and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's finishing kitchen and in the main kitchen. Findings include: An observation on August 10, 2021, at 11:30 AM in the finishing/serving kitchen, revealed the following: The filter on the front of the ice machine was covered in dust buildup. Multiple open shelf storage units were observed in the finishing kitchen, the shelves were sticky and dusty. The slotted bottom shelves located 6 inches from the floor, contained pots, pans, and inverted plastic bins. There was no solid barrier to prevent the contamination from mop water splash or sweeping debris from the items to be used in food preparation/service. […]

• No harm, potential for more than minimal, patternF584Dec 18, 2024

  Based on staff interview and review of facility documentation, it was determined that the facility failed to enusure that comfortable air temperature levels for residents on 2 of 2 nursing units (Cherry and Magnolia units). Findings include: Review of information submitted to the State Survey Agency on November 20, 2024 at 3:00 p.m. indicated that the facility was currently experiencing an issue with their Heating, Ventilation, and Air conditioning system (HVAC) that operates the rooms on the Cherry and Magnolia nursing units. The information submitted by the facility to the State Survey Agency indicated that the facility increased the heat in the hallways to supplement the temperatures in the rooms, and that the heating system for resident hallways and dining rooms were not affected. […]

• No harm, potential for more than minimal, patternF684Aug 13, 2021

  Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weight monitoring for one of 16 residents reviewed (Resident 54). Findings include: Clinical record review for Resident 54 revealed current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 54's weight documentation and July and August 2021 MAR (Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] July 19, 2021 July 21, 2021 July 22, 2021 August 4, 2021 August 5, 2021 August 9, 2021 On the following dates, staff indicated N/A (not applicable) for Resident 54's daily weight documentation: July 26, 2021 July 29, 2021 August 2, 2021 August… […]

• No harm, potential for more than minimal, patternF695Aug 13, 2021

  Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide supplemental oxygen care consistent with professional standards of practice for two of two residents reviewed for supplemental oxygen use (Residents 38 and 56). Findings include: The facility policy entitled, Oxygen Administration/Safety, last reviewed on January 20, 2021, revealed that oxygen cylinders must be stored in racks with chains, sturdy portable carts, and/or oxygen stands. Staff are to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the flow rate administration is above four liters, add distilled water to the humidifier bottle. […]