Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Brook Christian Home during CMS and state inspections, most recent first.
Legionella surveillance was not followed when repeated hot water temperature logs showed readings below the facility’s control measures for both county and city water systems. The Maintenance Director confirmed the temperatures were below the required levels and there was no documentation of any corrective action. The facility policy required hot water to be stored at 138 to 142 degrees F and circulated at a minimum return temperature of 124 degrees F.
Failure to Update Fall Intervention in Care Plan: A resident with dementia, HTN, and insomnia was found on the floor mat beside her bed, and a silent bed alarm was used as the immediate fall intervention. Although an IDT note and MD order referenced the alarm, the comprehensive care plan was not updated to include the silent bed alarm in the resident’s fall care plan, and the Regional Nurse confirmed the omission.
A resident with dementia, HTN, and later protein-calorie malnutrition did not have a baseline weight obtained and verified on admission, despite facility policy requiring admission weighing and weekly weights for the first 3 weeks if condition allows. The only initial weight in the record was reported by family from an outside facility, and the first facility weight was not recorded until about 2 weeks later; the RD and Administrator described a possible process error and noted the resident had respiratory complications around admission, but no explanation was given for the delay in obtaining weights.
Two residents had unclear PRN pain medication orders without defined pain-scale parameters or maximum acetaminophen limits. One resident received oxycodone and acetaminophen for pain ratings that did not match the intended severity, and the acetaminophen regimen could total over 4,000 mg/day. Another resident received tramadol and Tylenol for varying pain levels, including Tylenol given with tramadol, while the MAR gave no clear direction on which analgesic to use based on pain severity. Interviews confirmed the orders were confusing and lacked guidance for nursing judgment.
A resident with advanced dementia and significant care needs sustained a large skin tear of unknown origin following a mechanical lift transfer. Staff did not immediately investigate or determine the cause, and the incident was not reported to the state agency until days later, after the family raised concerns. The facility's delay in reporting the injury of unknown origin was not in accordance with required protocols.
A resident with advanced dementia and physical dependency sustained a significant skin tear, but staff did not promptly investigate the cause. The nurse on duty did not question staff involved in the resident's care at the time of the injury, and the formal investigation was delayed until after the family raised concerns. Facility policy requiring immediate investigation was not followed, and the incident report was incomplete until after the investigation was concluded.
Two residents suffered significant injuries due to improper use and maintenance of mechanical lifts. In one case, staff used an incorrect sling, causing it to break and the resident to fall, resulting in multiple rib fractures and a scalp contusion. In another case, a resident was struck in the head by the swivel bar of the lift after a transfer, leading to a laceration that required staples. Both incidents were linked to staff not following manufacturer instructions for sling compatibility and lift component safety.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident with anxiety and depression had no care plan for their medications, another with vascular wounds and diuretic use lacked appropriate care planning, and a resident with hearing impairment had no interventions for their condition. Additionally, a resident at high risk for wandering had no preventive measures in place, and another on antidepressants lacked a care plan for medication use.
A resident, who was cognitively intact and had no behavioral issues, was not allowed to stay in her room as per her preference due to a high fall risk. Despite her distress and requests to return to her room, she was kept in common areas for safety reasons, with staff citing the need for one-on-one assistance. This practice failed to honor her right to a dignified existence and self-determination.
A resident's bathroom was improperly used for storing incontinence briefs, creating a disorderly and uncomfortable environment. Despite the resident's requests to store the briefs in her closet, staff continued to use the bathroom for storage due to limited closet space.
The facility failed to conduct restraint assessments for alarm devices used on two residents, leading to a deficiency. One resident with dementia and a high fall risk felt restricted by a chair alarm, while another resident with intact cognition disliked the noise from alarms on her chair and bed. The DON confirmed that restraint assessments were not conducted for alarms, as they were not considered restraints.
A facility failed to provide a written bed-hold notice to a resident's representative during a hospital transfer. The resident, with multiple health issues, was transferred without the required notice, despite the family's financial concerns. Staff interviews revealed a lack of documentation and follow-up, and a misunderstanding regarding the policy for long-term residents.
A resident with multiple diagnoses and moderate cognitive impairment experienced a deficiency in care when the facility failed to change her dressing for a skin tear as ordered by the physician. Despite a physician's order for dressing changes every Monday, Wednesday, and Friday, observations revealed that the dressing had not been changed since the previous Wednesday. Interviews with staff confirmed the oversight, and the facility's policy required adherence to physician's orders for wound treatment.
A facility failed to ensure a safe environment by improperly storing portable oxygen tanks in a resident's room. Three tanks were found, with one freestanding and unsecured, contrary to the facility's oxygen safety policy requiring secure storage. A CNA confirmed the tanks were not in use and should have been returned to the designated storage room.
The facility failed to document nutritional supplement intake and complete an annual nutrition assessment for three residents, affecting their nutritional management. A resident with cognitive impairment and malnutrition experienced weight loss without documented supplement intake. Another resident with severe cognitive impairment had no recorded intake of supplements like Magic cups and Ensure, impacting care plan adjustments. A third resident did not receive a timely nutritional assessment, and supplement intake was not documented, potentially affecting nutritional management.
The facility failed to follow medication administration parameters for two residents. One resident received Sotalol outside prescribed blood pressure parameters without pulse checks, while another on anticoagulant therapy lacked documented monitoring for bleeding or bruising. These deficiencies were confirmed by staff interviews.
A facility failed to identify and monitor targeted behaviors for a resident prescribed Zoloft for depression. Despite the resident being cognitively intact and having multiple diagnoses, there was no care plan or documentation for the use of Zoloft. Behavior tracking documents were generic and did not specify targeted behaviors, as confirmed by interviews with the MDS Nurse and DON.
A facility failed to properly sanitize a glucometer used for multiple residents on the Skilled Unit. An RN was observed swiping the glucometer with a sani wipe without allowing the manufacturer's recommended two-minute dry time, placing it on surfaces without barriers, and returning it to the medication cart without sanitizing. The facility's policy required cleaning and disinfecting glucometers between patients to prevent the spread of bloodborne pathogens.
Two residents received inappropriate antibiotic prescriptions due to the facility's failure to follow its antibiotic stewardship program. One resident was prescribed antibiotics for a UTI without meeting the McGeer criteria, and another was given antibiotics before urine culture results were available. The facility did not adhere to established protocols, leading to deficiencies in antibiotic management.
Legionella Water Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure its Legionella plan parameters for water temperature readings were followed and failed to initiate new interventions when documented temperatures were below the control measure. Review of the Legionella plan dated 07/2025 showed the facility was to check the outflow and return temperatures of the domestic water heaters, with control temperatures of 118 degrees F for the county water and 140 degrees F for the city water. Review of the 2026 monthly temperature logs showed repeated readings below the control measure for both systems: the county water heater readings were 110 and 112 degrees F in January, 113 and 115 degrees F in February, 110 and 111 degrees F in March, and 116 and 118 degrees F in April; the city water readings were 111 and 113 degrees F in January, 109 and 111 degrees F in February, 110 and 110 degrees F in March, and 111 and 112 degrees F in April. During interview, the Maintenance Director confirmed the readings were below the control measures and there was no documentation of what the facility did to correct it. Review of the facility policy titled Legionella Surveillance dated 10/01/25 stated hot water shall be stored at 138 to 142 degrees F and circulated at a minimum return temperature of 124 degrees F.
Failure to Update Fall Intervention in Care Plan
Penalty
Summary
The facility failed to ensure Resident #45’s comprehensive care plan was updated to include a fall intervention after she was found on the floor mat beside her bed on 01/16/26. The resident’s record showed she was admitted with diagnoses including hypertension, insomnia, and dementia, and her MDS indicated she was rarely or never understood, was alert but unable to make her needs known, and was dependent on staff for transfers, toileting, and personal hygiene. An investigation report documented that a silent bed alarm was used as the immediate action after the fall, and an IDT note on 01/20/26 stated that a silent alarm was to be applied when the resident was in bed and that the POC was reviewed and updated. Review of the physician’s orders showed an order for a silent alarm to bed every shift, and the care plan dated 02/23/26 included an at-risk-for-falls care plan. However, the care plan did not include an updated intervention for the silent bed alarm that had been implemented after the fall. During interview on 04/30/26, the Regional Nurse confirmed the comprehensive care plan was not updated to include the silent bed alarm intervention for the resident’s fall.
Delayed Baseline Weight Measurement After Admission
Penalty
Summary
The facility failed to ensure baseline weight measurements were obtained and verified in a timely manner after admission for one resident with diagnoses including unspecified dementia, hypertension, and later unspecified protein-calorie malnutrition. The resident’s cognition could not be assessed with a standardized tool because the resident was rarely or never understood, and daily decision-making skills were noted to be impaired. The medical record showed an initial weight of 146 lbs documented as measured before admission, but the next recorded weight was not entered until two weeks after admission, when the resident weighed 130 lbs. During interview, the RD stated the 146-lb weight had been reported by the resident’s family as having been measured at an outside facility, and the facility policy required weighing a new resident on admission and then weekly for the next three weeks unless otherwise ordered. The Administrator stated there may have been a process error that resulted in no weight being recorded on admission, and described the usual process as nursing aides measuring weights on paper and nurses entering them into the EHR. The RD later verified that no weights were obtained at the facility until the resident’s weight was recorded about two weeks after admission, and stated the resident had respiratory complications around the time of admission, but there was no explanation for why weights were not measured during the following two weeks as required by policy.
Unclear Pain Medication Orders and Dosing Parameters
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary drugs when pain medication orders lacked clear parameters for use. For one resident with diagnoses including right below-knee amputation, encephalopathy, dysphagia, kidney disease, atrial fibrillation, heart failure, hypertension, edema, and Parkinson’s disease, orders were written for scheduled and PRN acetaminophen and oxycodone, but the MAR contained no guidance on when to give oxycodone versus acetaminophen and no maximum daily acetaminophen dose. The resident received oxycodone for pain ratings as low as 2 out of 10 and acetaminophen for an 8 out of 10 pain rating, and the ordered acetaminophen regimen could total 4,225 mg daily. For another resident with atrial fibrillation, heart failure, hypertension, edema, and Parkinson’s disease, orders included PRN tramadol and later PRN Tylenol with instructions to give Tylenol with tramadol for severe pain. The MAR showed tramadol being administered for pain ratings ranging from 2 out of 10 through 10 out of 10, and Tylenol was also given for low pain ratings and at times along with tramadol. The MAR again lacked parameters identifying when staff should administer one medication versus the other, and there was no clear direction on which PRN pain medication to use based on pain level. Interviews confirmed the orders were unclear and that nursing staff were not given guidance on pain-scale thresholds for either resident. An RN stated pain levels 1 to 5 were mild/moderate and 5 to 10 were moderate/severe, while the regional nurse confirmed the orders did not provide instructions and that acetaminophen should not exceed 3,000 mg daily, with 4,000 mg being high. The NP stated she did not like using parameters in orders, wanted nursing judgment used, and acknowledged that acetaminophen should not exceed 3,000 mg daily, while also confirming the first resident’s acetaminophen orders could exceed 4,000 mg per day and that the second resident’s order was confusing and not clearly written.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin sustained by a resident was reported in a timely manner to the state agency, as required by policy. The resident involved had multiple diagnoses, including dementia with behavioral disturbance, malnutrition, and late-onset Alzheimer's disease, and was dependent for all activities of daily living and mobility. The resident was known to have fragile skin and was to wear protective geri-sleeves, and required transfers using a Hoyer lift. On the morning of the incident, staff discovered a significant skin tear on the resident's arm after a Hoyer transfer, but there was no clear indication of how the injury occurred. Staff interviews revealed that the nurse on duty was informed of the injury but did not immediately investigate or ask staff present about the cause. The incident report was incomplete at the time of the initial documentation, with the section regarding the cause of the injury left blank until after the facility's investigation was completed. The Director of Nursing was not informed of the injury until the following day during a care conference with the resident's family. The facility's investigation later suggested the injury may have been caused by a buckle on the resident's Broda chair, but this determination was made after the fact. Despite the facility's policy requiring timely reporting of injuries of unknown origin to the state agency, the incident was not reported until several days later, after the resident's family raised concerns. Multiple staff, including the DON and ADON, acknowledged that the cause of the injury was not immediately known and that reporting should have occurred promptly. The delay in reporting constituted non-compliance with regulatory requirements for timely notification of suspected abuse, neglect, or injury of unknown origin.
Failure to Timely Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including dementia with behavioral disturbance, malnutrition, and late-onset Alzheimer's disease, was dependent for all activities of daily living and mobility, and had interventions in place for fragile skin. A skin tear was discovered on the resident's arm during the morning shift, and while immediate wound care was provided and hospice was notified, the cause of the injury was not promptly investigated. Staff interviews revealed that the registered nurse who was informed of the injury did not ask staff present how the injury occurred and assumed it happened during a Hoyer lift transfer, but did not confirm this with those involved. Certified nursing aides involved in the transfer reported no incident during the transfer that would explain the injury and were unsure of its cause. The Director of Nursing was not informed of the injury until the following day, and the formal investigation into the incident was not initiated until several days later, after the resident's family alleged mistreatment. Documentation showed that staff statements and interviews were only obtained after the family complaint, and the incident report was not fully completed at the time of the injury. The facility's policy required an immediate investigation upon suspicion of abuse or neglect, including prompt interviews and documentation, but this was not followed. The investigation ultimately did not determine a definitive cause for the injury but found no evidence of abuse or neglect.
Failure to Ensure Safe Mechanical Lift Use and Maintenance Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure the safe use and maintenance of mechanical lifts, resulting in significant injuries to two residents. In one incident, a resident with multiple medical conditions, including schizoaffective disorder, diabetes, Parkinson's disease, and mild cognitive impairment, required extensive assistance and the use of a mechanical lift for transfers. During a transfer, staff used an incorrect, thin hospital sling that was not designed for the specific lift, leading to the sling breaking and the resident falling to the floor. The resident sustained multiple rib fractures and a scalp contusion, requiring admission to a surgical trauma intensive care unit. In a separate incident, another resident with dementia, hemiplegia, and a history of stroke, also dependent on staff and a mechanical lift for transfers, was injured when the metal swivel bar of the lift struck her forehead after a transfer. The impact caused a laceration that required four staples. The incident occurred when only one staff member remained in the room while moving the lift away from the resident, resulting in the injury. Both incidents were confirmed through medical record review, staff interviews, and observation. The facility's failure to use the appropriate sling for the mechanical lift and to maintain the lift according to the manufacturer's instructions directly contributed to the residents' injuries. The manufacturer's guidelines specified that only designated slings should be used with the lift and that protective padding should be present on the swivel bar, which was not consistently followed.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. Resident #34, who was admitted with diagnoses including major depressive disorder and anxiety disorder, had physician orders for medications such as Clonazepam, Sertraline, and Lorazepam. However, the care plan did not address the use of these medications for anxiety and depression, as confirmed by MDS Nurse #113. Resident #10, with diagnoses including chronic respiratory failure and unspecified dementia, had a vascular wound and was prescribed a diuretic, chlorthalidone. Despite ongoing skin assessments revealing a persistent vascular wound, the care plan did not include the use of diuretics or address the resident's vascular wounds. MDS Nurse #113 confirmed the absence of these care plans, which should have been included. Resident #12, who had a hearing impairment and was scheduled to see an audiologist, did not have her hearing issues addressed in her care plan. Interviews revealed that her hearing aid was broken, affecting her communication. Similarly, Resident #41, at high risk for wandering due to severe cognitive impairment, had no interventions in place to prevent wandering or elopement. Lastly, Resident #15, prescribed Zoloft for depression, lacked a care plan addressing the use of this medication. MDS Nurse #113 confirmed these omissions, which were contrary to the facility's policy requiring comprehensive care plans.
Resident's Right to Dignity and Self-Determination Not Honored
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not allowing her to remain in her room as per her preference. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was admitted with multiple diagnoses including hypertension, anxiety disorder, and chronic pain syndrome. Despite having no behavioral problems, the resident was subjected to a physician's order that required her to be monitored at all times outside of her room, with a personal alarm attached to her chair and bed. This order was enforced after an incident where the resident attempted to get out of bed without support, leading to a decision by the facility to keep her in common areas for safety reasons. The resident expressed frustration and distress over not being allowed to spend time in her room, even for basic needs like using the bathroom. Observations confirmed that the resident was kept in the common area, often sitting in her wheelchair watching TV, with staff citing her high fall risk as the reason for this practice. Interviews with staff revealed that the resident was kept in the common area to ensure she received one-on-one assistance due to staffing constraints, which prevented her from exercising her right to self-determination and dignity by choosing to stay in her room.
Improper Storage of Incontinence Briefs in Resident's Bathroom
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident, identified as Resident #35, by improperly storing incontinence briefs in her bathroom. Observations over three consecutive days revealed that between 11 and 12 packages of incontinence briefs were stacked and stored along the wall in the resident's bathroom. Some packages were opened, with briefs scattered randomly on the floor and on top of unopened packages, creating a disorderly and uncomfortable living space for the resident. Resident #35, who has multiple diagnoses including retention of urine, hypertension, and anxiety disorder, expressed dissatisfaction with the use of her bathroom as a storage area for her personal incontinence briefs. She confirmed that she had requested several times for the briefs to be stored in her closet instead. A Certified Nursing Assistant (CNA) confirmed the storage situation and stated that the briefs were kept in the bathroom for easy access due to the resident's small closet size.
Failure to Conduct Restraint Assessments for Alarm Devices
Penalty
Summary
The facility failed to document ongoing assessments to evaluate the need for the use of physical restraints, specifically alarm devices, for two residents. Resident #28, who has multiple diagnoses including dementia and a high risk for falls, was observed with a chair alarm in place. The resident expressed feeling restricted by the alarm, which would sound loudly if she attempted to stand, deterring her from moving independently. The Director of Nursing (DON) confirmed that the facility does not conduct restraint assessments for alarms, as they are not considered restraints, despite having physician's orders for their use. Similarly, Resident #300, with intact cognition and no behavioral problems, was also subjected to the use of alarms on her chair and bed without documented restraint assessments. The resident expressed dislike for the noise made by the alarms when she attempted to stand. Observations confirmed the presence of alarms, and the DON acknowledged the lack of restraint assessments for this resident as well. The facility's practice of using alarms without proper assessments was identified as a deficiency by the surveyors.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident's representative during a hospital transfer, affecting one resident out of two reviewed for such transfers. The resident, who was moderately cognitively impaired and required assistance with daily activities, was admitted with multiple diagnoses including dementia and chronic kidney disease. The resident's wife expressed financial concerns regarding the cost of care, as their long-term care insurance only covered a portion of the daily expenses. Despite these concerns, there was no evidence that the facility provided the required bed-hold notice at the time of the resident's transfer to the hospital. Interviews with facility staff revealed that nursing staff were responsible for completing and delivering the bed-hold notice to emergency medical personnel, who would then pass it to hospital staff. However, there was no documentation confirming that the notice was delivered to the resident's wife. The facility's policy required a signed and dated copy of the bed-hold notice to be kept in the resident's file, but this was not done. Staff interviews indicated a lack of follow-up to ensure the notice was received, and a misunderstanding that long-term residents paying monthly were exempt from receiving the notice.
Failure to Adhere to Dressing Change Schedule for Resident's Skin Tear
Penalty
Summary
The facility failed to ensure that dressing changes for a skin tear on Resident #34's left hand were completed as ordered by the physician. Resident #34, who has diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy, was admitted with moderate cognitive impairment. Following a fall on 10/26/24, Resident #34 sustained an injury to her left hand, which was initially treated with a dressing. A physician's order dated 10/28/24 specified that the dressing should be changed every Monday, Wednesday, and Friday, using normal saline, xeroform, a nonadherent dressing, and Kerlix. However, observations on 11/04/24 revealed that the dressing on Resident #34's left hand was dated 10/30/24, indicating that the dressing had not been changed according to the prescribed schedule. Interviews with a CNA and an LPN confirmed that the dressing was not changed as ordered, and the Director of Nursing verified that there were no wound measurements until 10/28/24. The facility's policy on 'Wound Treatment Management' required that wound treatments be provided in accordance with physician's orders, including the frequency of dressing changes, which was not adhered to in this case.
Improper Storage of Portable Oxygen Tanks
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by improperly storing portable oxygen tanks in a resident's room. During an observation, three portable oxygen tanks were found in the room of a resident, with two tanks stored on a transport cart and one tank freestanding and unsecured, leaning against the wall. A Certified Nursing Assistant (CNA) confirmed that the oxygen tanks were not in use and that the freestanding tank should have been secured on a cart. The facility's policy on oxygen safety, revised earlier in the year, mandates that oxygen storage locations should be enclosed and that cylinders must be properly secured to prevent falling, whether they are connected, unconnected, full, or empty.
Deficiency in Nutritional Supplement Documentation and Assessment
Penalty
Summary
The facility failed to document nutritional supplement intake and complete an annual nutrition assessment for three residents, leading to deficiencies in monitoring and managing their nutritional needs. Resident #25, who was moderately cognitively impaired and had a history of acute kidney failure, dementia, and malnutrition, experienced a 5.5% weight loss over two months. Despite being ordered to receive Glucerna with meals, there was no documentation of the amount consumed, and staff confirmed that supplement intake was not recorded, which could hinder accurate monitoring of the resident's nutritional status. Resident #41, who was severely cognitively impaired and had a history of dementia and malnutrition, also had no documented intake of nutritional supplements like Magic cups and Ensure. Although the resident's weight increased slightly, the lack of specific documentation on supplement consumption could affect the ability to monitor and adjust the resident's nutritional care plan. Interviews with the DON, ADON, and dietician confirmed the absence of detailed documentation, which is necessary for accurate assessment and timely intervention. Resident #36, with severe cognitive impairment and multiple health issues, did not receive an annual nutritional assessment as required. The last assessment was completed over a year ago, and there was no documentation of the amount of Ensure consumed during meals. The dietician acknowledged the oversight in completing the annual assessment and the lack of documentation on supplement intake, which could impact the resident's nutritional management. Interviews with staff confirmed that they only documented whether the supplement was provided, not the amount consumed.
Failure to Follow Medication Administration Parameters and Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to adhere to medication administration parameters for two residents, leading to deficiencies in care. Resident #33, who had multiple diagnoses including hypertension and atrial fibrillation, was prescribed Sotalol with specific parameters to hold the medication if blood pressure was below 110/70 or heart rate was below 60. However, the resident received Sotalol on several occasions when the blood pressure was outside these parameters, and there was no documentation of pulse checks at the time of administration. This indicates a failure to follow the physician's orders and monitor the resident's vital signs appropriately. Resident #25, diagnosed with conditions such as acute kidney failure and atrial fibrillation, was on anticoagulant therapy. The care plan required monitoring for signs of bleeding or bruising, which are critical due to the risks associated with anticoagulant use. However, there was no documentation of such monitoring from the time of admission until a later date, despite the resident being on anticoagulant therapy. This lack of documentation suggests a failure to monitor the resident for potential side effects of the medication, as confirmed by interviews with facility staff.
Failure to Monitor Targeted Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to adequately identify and monitor targeted behaviors for a resident using psychotropic medication, specifically Zoloft, which was prescribed for depression. The resident, who was cognitively intact, had a range of diagnoses including atrial fibrillation, shoulder pain, and heart failure. Despite being prescribed Zoloft, there was no care plan in place to address the use of this medication, nor were there any interventions or documentation identifying targeted behaviors for its use. Behavior tracking documents for the resident listed a variety of potential behaviors but did not specify any targeted behaviors related to the use of Zoloft. Interviews with the MDS Nurse and the Director of Nursing confirmed the absence of a care plan and the lack of individualized behavior tracking. The facility used a generic behavior tracking log that did not identify or monitor specific behaviors for the resident, leading to the deficiency noted in the report.
Improper Sanitization of Glucometer
Penalty
Summary
The facility failed to properly sanitize a multi-use glucometer, which had the potential to affect three residents receiving glucometer checks on the Skilled Unit. During an observation, a Registered Nurse (RN) was seen swiping the top of the glucometer with a sani wipe before entering a resident's room. The RN placed the glucometer on the over bed table without a barrier, performed a finger stick blood glucose stick (FSBS) check, and then placed the glucometer on the medication cart without using a barrier. The RN documented the FSBS in the electronic health record and returned the glucometer to the medication cart without cleansing or sanitizing it. An interview with the RN confirmed that one glucometer was used for the three residents on the skilled unit who required FSBS checks. The RN admitted to not sanitizing the glucometer before placing it back in the medication cart. Additionally, the observation of the sani-wipe container revealed that the manufacturer's directions required a two-minute dry time, which was not followed. The facility's undated Glucometer Policy and Procedure aimed to prevent the spread of bloodborne pathogens and recommended cleaning and disinfecting glucometers between patients, following the manufacturer's directions.
Inappropriate Antibiotic Prescriptions Due to Non-Adherence to Protocols
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic prescriptions for two residents. Resident #101 was admitted with a urinary tract infection (UTI) suspected to have developed during a hospital stay. Despite the absence of symptoms such as fever, dysuria, or increased urinary frequency, and without a urine culture to confirm the infection, antibiotics were prescribed. The Assistant Director of Nursing (ADON) acknowledged that the McGeer criteria for antibiotic usage were not met, and there was a lack of necessary lab results to support the antibiotic prescription. Resident #33 experienced hallucinations, which the resident's son associated with the onset of a UTI. A urine analysis was ordered, and antibiotics were prescribed before the culture results were available. The infection log later identified pseudomonas aeruginosa, leading to multiple changes in antibiotic prescriptions. The Director of Nursing (DON) confirmed that the process for handling UTIs was not followed, as antibiotics were administered before obtaining urine analysis results. The revised McGeer criteria require both signs and symptoms and microbiologic criteria before administering antibiotics, which were not met in this case. The report highlights the facility's failure to follow established protocols for antibiotic usage, resulting in inappropriate treatment for both residents. The lack of adherence to the McGeer criteria and the premature administration of antibiotics without supporting lab results contributed to the deficiencies identified by the surveyors.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highbanks Care Center | 0.2 mi | ★★★★★ | 8 | 0 |
| Worthington Christian Village | 0.5 mi | ★★★★★ | 10 | 0 |
| Laurels Of Norworth The | 2.3 mi | ★★★★★ | 5 | 0 |
| Laurels Of Worthington, The | 2.9 mi | ★★★★★ | 0 | 0 |
| Capri Gardens | 3.6 mi | ★★★★★ | 8 | 0 |
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