Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cherith Care Center At Willow Brook during CMS and state inspections, most recent first.
The facility did not ensure an RN was present for at least eight consecutive hours each day, as required, with multiple days across several months lacking RN coverage. Staff confirmed that on some days, the RN assigned to assisted living was counted as coverage for the nursing home.
The facility did not fully complete required ABN forms for two residents, omitting key information such as the start date for potential financial liability and estimated service costs, as confirmed by a social worker and in contrast to facility policy.
A resident with multiple comorbidities and a sacral SDTI did not receive physician-ordered wound care, including cleansing, zinc barrier cream, and foam dressing as prescribed. Documentation showed the last treatment was performed several days before observation, and during care, the required dressing was not present. Staff and DON confirmed the treatment was not provided as ordered.
A resident with a history of dementia and wandering exited the facility unsupervised through an unalarmed door, sustaining minor injuries. Despite prior wandering behaviors, the resident was not assessed as a wandering risk and did not have an elopement care plan. After the incident, the facility failed to conduct a comprehensive assessment or thorough investigation, and staff statements or a root cause analysis were not documented.
Two residents at risk for constipation, both dependent on staff for toileting and with significant medical histories, did not receive appropriate interventions as outlined in their care plans. Despite several days without a bowel movement, as-needed laxatives were not administered and there was no documentation that the facility's bowel protocol was followed. Nursing staff confirmed the absence of a system to ensure protocol adherence.
A resident with multiple diagnoses was receiving several psychotropic medications without a documented rationale for not attempting a gradual dose reduction, despite pharmacy recommendations and facility policy requiring such documentation. The physician indicated a dose reduction was contraindicated but did not provide an explanation, and this omission was confirmed by the DON.
A resident with cognitive impairment and multiple chronic conditions experienced a fall after sliding out of a recliner while being repositioned by a CNA. The incident was documented in the facility's incident log and reviewed by committee, but required documentation such as nurse's notes, vitals, assessment, and follow-up was missing from the resident's medical record, contrary to facility policy.
Three residents with complex medical conditions received influenza vaccinations without documented consent or evidence of receiving required vaccine education. Review of records and staff interviews confirmed that the facility did not follow its policy to provide CDC vaccine information statements and obtain signed consent forms prior to administering the vaccine.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours, seven days a week, as required. Review of the Payroll Based Journal (PBJ) and RN schedules for the months of October, November, and December 2024 showed multiple days each month with no RN coverage in the nursing home. Specifically, there were four days in both October and December, and five days in November, when no RN was present. Staff interviews confirmed that the facility did not always have an RN scheduled to provide care and that, on some occasions, the RN working in the assisted living area was counted as coverage for the nursing home. The facility census during this period was 30 residents.
Incomplete Advance Beneficiary Notices Provided to Residents
Penalty
Summary
The facility failed to provide complete and accurate information on the Skilled Nursing Facility Advance Beneficiary Notice (ABN) forms for two residents. For one resident with multiple diagnoses including dementia, chronic kidney disease, and pressure ulcer, the ABN form was missing the required 'beginning on' date, which is necessary to inform the resident when they may become financially responsible for services. This omission was confirmed by the social worker during an interview. For another resident with diagnoses such as hypertension, COPD, vascular dementia, and dysphagia, the ABN form was also missing the 'beginning on' date and did not include the estimated cost per day or per service. The social worker confirmed these omissions during an interview. Review of the facility's policy indicated that the ABN should be fully completed to inform Medicare beneficiaries of their potential liability, but this was not followed in these cases.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician-ordered wound treatments were provided as prescribed for a resident with a suspected deep tissue injury (SDTI) on the sacrum. The resident, who had multiple diagnoses including dementia, chronic kidney disease, cirrhosis, malignant neoplasm of the breast, urinary incontinence, Alzheimer's disease, anorexia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss, was admitted with a care plan and physician orders specifying cleansing the sacrum, applying zinc barrier cream, and covering with a foam dressing every three days and as needed. Record review showed that the last documented treatment was performed several days prior to the observation, with no as-needed treatments recorded. During incontinence care, it was observed that the resident did not have the required foam dressing in place, nor was it found in the bed or removed during care. Staff interviews confirmed the absence of the dressing, and the DON acknowledged that staff are expected to follow wound treatment orders as written. Facility policy required wound treatments to be provided according to physician orders, including dressing type and frequency.
Failure to Prevent Resident Elopement and Incomplete Post-Incident Investigation
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's disease, dementia, and other significant medical conditions exited the facility unsupervised. The resident had previously demonstrated wandering behaviors, including not staying in bed or in his room, and had a documented history of wandering at home. Despite these behaviors, the facility's assessments identified the resident as low risk for wandering and did not implement a wandering or elopement care plan. The resident's care plan focused on fall prevention, with interventions such as a bed and chair alarm, but did not address the risk of elopement. On the night of the incident, the resident was able to leave the building through an exit that was not alarmed at the time. Staff discovered the resident missing only after he had already exited, and he was found outside the facility with minor injuries. The bed alarm intended to alert staff was not sounding, and staff were unable to confirm if it had been activated. The facility's elopement and wandering policy required systematic identification, assessment, and monitoring of residents at risk for elopement, but these procedures were not fully followed in this case. Following the incident, there was no comprehensive assessment or thorough investigation documented. The facility did not collect staff statements or conduct a root cause analysis, and the investigation was not included in the resident's medical record. The lack of a timely reassessment and care plan update after the resident's wandering behaviors, as well as the absence of a complete investigation after the elopement, contributed to the deficiency.
Failure to Follow Bowel Protocol for Constipation Management
Penalty
Summary
The facility failed to follow its bowel protocol for constipation management for two residents who were at risk due to their medical conditions and dependency on staff for toileting. For one resident with osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain, the care plan required monitoring and recording bowel movements every shift and administering as-needed laxatives if no bowel movement occurred in three days. Despite this, documentation showed the resident did not have a bowel movement for five days, and no as-needed laxatives were administered during that period. The registered nurse confirmed there was no system in place to ensure the bowel protocol was followed. Similarly, another resident with major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder, who was also always incontinent and dependent on staff, did not have a bowel movement for four days. The care plan included several as-needed interventions for constipation, but no as-needed laxatives were given, and there was no documentation of the bowel protocol being followed. The registered nurse again verified the lack of a system to ensure adherence to the protocol. Both cases were confirmed through record review, standing orders, and staff interviews.
Failure to Document Rationale for Not Reducing Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a rationale was documented for not attempting a gradual dose reduction (GDR) of psychotropic medications for a resident. The resident, who had diagnoses including major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder, was receiving Zoloft, mirtazapine, and hydroxyzine. The consulting pharmacist recommended a GDR or, if not appropriate, required a documented explanation as to why a GDR would be detrimental. The physician reviewed and signed the pharmacy recommendations, indicating that a GDR was contraindicated, but did not provide any rationale for this decision. This omission was confirmed during an interview with the DON. Facility policy required that if a physician declined a pharmacist's recommendation, an explanation should be documented in the medical record, and if not, the DON should be notified and the issue brought to the QAPI committee. In this case, the required rationale was not documented, resulting in noncompliance with facility policy and regulatory expectations.
Failure to Maintain Complete Medical Records for Resident Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records related to resident incidents, specifically regarding a fall experienced by a resident with multiple diagnoses including osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. The resident, who had cognitive impairment, was found on the floor after sliding out of a recliner while being repositioned by a CNA. Although the incident was recorded in the facility's incident and accident log and discussed in a committee review, the documentation was not included in the resident's official medical record. There was no nurse's note, vital signs, assessment, investigation, or follow-up documentation in the medical record regarding the fall. The DON confirmed that accidents and falls were documented in incident reports, which were not part of the medical record, and verified the absence of required documentation for the incident. The facility's Fall Prevention Program policy required assessment, incident reporting, physician and family notification, care plan review and updates, documentation of all assessments and actions, and witness statements when applicable, but these steps were not reflected in the resident's medical record.
Failure to Obtain Consent and Provide Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to obtain consent and provide education prior to administering the influenza vaccine to three residents. For each of these residents, medical record review showed that the influenza vaccination was given, but there was no documentation of a signed consent form or evidence that vaccine information or education was provided before administration. Interviews with the MDS Coordinator confirmed that the required consent forms and educational documentation were missing for all three residents. The affected residents had complex medical histories, including diagnoses such as dementia, chronic kidney disease, cirrhosis, Alzheimer's disease, malnutrition, chronic obstructive pulmonary disease, and other serious conditions. Despite the facility's policy requiring that the CDC's vaccine information statement be provided and consent obtained prior to vaccination, these steps were not documented or completed for the residents in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Delaware
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Center V, Inc | 1 mi | ★★★★★ | 6 | 0 |
| Ohio Living Sarah Moore | 2.1 mi | ★★★★★ | 12 | 0 |
| Delaware Court Health Care Center | 2.3 mi | ★★★★★ | 18 | 0 |
| Arbors At Delaware | 3.4 mi | ★★★★★ | 35 | 0 |
| Capri Gardens | 6.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.