Champions Healthcare At Willowbrook

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident who was unable to complete ADLs received timely assistance off the bedpan. Resident #66 had diagnoses including injury of the muscle, fascia, and tendon of the posterior thigh, muscle weakness, and reduced mobility. Her MDS showed intact cognition, lower-extremity ROM impairment on one side, and frequent bowel incontinence with occasional urine incontinence. Her care plan identified an ADL self-care performance deficit and required staff participation for toilet use and bed mobility, and she also had chronic pain with analgesics ordered as needed. On 4/20/26, Resident #66 used a bedpan for toileting. According to the LVN’s statement, the resident called for pain medication and said she needed help off the bedpan. The LVN asked her to wait a few minutes while the CNA finished showering another resident, left the room, and later returned to reassure her that the CNA would assist shortly. The LVN then went to the nurses’ station for medication-related tasks. The CNA’s statement indicated she was occupied with other resident care and later entered the room to help. Resident #66 stated she had been left waiting on the bedpan for an extended period and was upset about having to wait. During interview and observation on 4/21/26, Resident #66 said she had been left on the bedpan many times for 30 minutes to one hour and that her buttock was red from sitting on it so long. She showed a photo of a bright red imprint around the sacral area and said the experience affected her spiritually, emotionally, and physically. The DON stated all nursing staff could assist with incontinent care and expected the LVN to remove the resident from the bedpan when first answering the call light. The Administrator stated the LVN did not follow call light expectations and that the issue was a failure of call light response. Resident #66 later stated the nurse told the aide, who was already busy, to assist her, which made her feel awful and less than, and she reported having four spasms while on the bedpan.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from abuse when one resident slapped another resident in the chest in the hallway near the dining room. The incident occurred while one resident was passing by the dining room and the other was seated by the dining room door with a walker nearby. The event was witnessed by a CNA, and the residents were separated after the altercation. The resident who was struck was assessed, and redness to the chest was noted with an x-ray ordered; the x-ray later showed no abnormalities. The resident who slapped the other resident had diagnoses including dementia, intellectual disabilities, convulsions, panic disorder, psychotic disorder, restlessness and agitation, and a history of mental and behavioral disorders. Her quarterly MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. Her care plan identified behavioral problems and noted that she had hit another resident the day before the incident. The resident who was struck also had a BIMS score of 6 out of 15, diagnoses including dementia, mixed anxiety and depressed mood, and psychosis due to a substance or known physiological condition, and her MDS documented frequent rejecting of care. Interviews and record review showed that the struck resident reported being scared after the incident, stated she asked staff to call an ambulance and the police, and said she felt unable to breathe for about five minutes after being hit. She also stated she could not sleep for two to three days and wanted someone to talk to about how she felt. Staff interviews reflected that the residents were separated and that the aggressor was placed on one-to-one supervision, but the record also showed the struck resident was not included in the safe surveys completed after the incident. The facility’s abuse policy defined abuse to include physical abuse such as slapping and stated that residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, and mistreatment.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen on the 1st floor. During observation, beef liver and onions with gravy, wheat dinner rolls, seasoned potatoes, chicken fingers, green peas, and mashed potatoes were being prepped and plated, and the first plate was placed on the service rack for delivery to residents without temperature checks being completed beforehand. During interview, the DM stated he had started the position two weeks earlier and could only locate temperature logs for March 2026, which were completed, while April 2026 logs were missing entries for lunch and dinner on 04/21/2026 and breakfast and lunch on 04/22/2026. He stated temperatures were expected to be checked when food came out of the oven and again on the steam table before serving, and that the cook was responsible for checking temperatures before service. The Administrator stated he was not familiar with the facility's food service policy and was not aware temperatures were not being checked. The Cook stated temperatures were expected to be checked before food was put on the line and again while on the line before serving, and acknowledged the temperature amount was not written down on 04/22/2026.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of one resident by not following manufacturer instructions and physician orders during medication administration. Resident #16 had dementia with severe cognitive impairment, diabetes, COPD, heart disease, and anxiety, and was receiving insulin and respiratory therapy. The resident’s orders included Budesonide nebulizer treatment with instructions to rinse the mouth and spit afterward, Lantus insulin 20 units subcutaneously twice daily, and Novolog insulin per sliding scale before meals and at bedtime. During observation of the medication pass, LVN E administered Novolog insulin and Lantus insulin without priming the insulin pen needles after attaching them. LVN E also held each insulin pen against the resident’s skin for 2 seconds after injection rather than the manufacturer-recommended time. For Novolog, the manufacturer instructions stated to keep the needle in the skin for at least 6 seconds, and for Lantus the instructions stated to slowly count to 10 before removing the needle. The resident’s Novolog dose of 2 units and Lantus dose of 20 units were documented as given, but the observed administration did not follow the manufacturer’s directions. During the same medication pass, LVN E administered Budesonide via nebulizer and then left the room without ensuring the resident rinsed her mouth with water and spit, as ordered. The resident stated she knew she was supposed to rinse and spit after the breathing treatment but was never asked to do so. In interview, LVN E stated he missed ensuring the resident rinsed and spit and acknowledged that not doing so could lead to thrush. The DON stated the facility expected nurses to ensure residents rinsed and spit after steroid breathing treatments and that the risk of not doing so would be thrush.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store drugs and biologicals in locked compartments and to limit access to authorized personnel for two residents reviewed for medication storage. The report states that Resident #57, who had diagnoses including chronic respiratory failure, pulmonary fibrosis, diabetes, dementia, and congestive heart failure, had a BIMS score of 12 indicating mild cognitive impairment and did not have a care plan showing that he could self-administer medications. During observation, an unidentifiable large white pill was found at the doorway of his room. Staff interviewed after the observation stated they did not know where the pill came from, and the DON stated medications should be swallowed and not left on the bedside. The report also found that Resident #42, who had diagnoses including dementia, psychotic disorder with hallucinations and delusions, anxiety disorder, cataract, and unspecified psychosis, had a BIMS score of 6 indicating moderate to severe cognitive impairment and could not reliably participate in complex decision-making without support. Her care plan addressed impaired visual function related to cataract, but it did not reflect that she could self-administer eye medication or include interventions for eye irritation. Her active physician orders and eMAR did not show any eye medications or eye drops. During observation in Resident #42's room, one eye-drop bottle was seen on the vanity desk and another on the in-room sink. Resident #42 stated she kept the eye drops in her room because her eyes burned every morning and said staff were aware that she was having and administering her own eye drops. The DON stated she had not been aware of the eye issues and reported that Resident #42 did not have an active order for self-administered medications. The facility policy stated that drugs and biologicals must be stored in a safe, secure, and orderly manner and that only authorized persons may have access to the medication room keys.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident CR #1’s medical record was accurate by not updating the resident’s advance directive and care plan after a completed DNR form was received from the physician and responsible party. CR #1 was an [AGE]-year-old male admitted on [DATE] with diagnoses including hypertension, malignant neoplasm of the liver, dementia, and malnutrition. His MDS assessment showed a BIMS score of 06 out of 15, indicating moderate to severe cognitive impairment and significant difficulty with short-term memory, recall, and orientation. The physician orders and care plan still reflected full code status, and the care plan included review of advance directives and preferences quarterly and PRN with the resident/responsible party. Record review showed an Out of Hospital DNR order with signatures from an immediate family member, two witnesses, and the physician, but the document was not uploaded into the electronic medical record and the code status was not updated. A nurse note documented that when CR #1 was found unresponsive, staff verified the active OOH DNR with the original form and another nurse, and CPR was not initiated per the DNR order. During interviews, the SW stated she kept physical copies of DNR forms but did not upload completed advance directive forms, and that the ADON was responsible for uploading the form and updating code status. The RN stated the signed DNR was provided to the ADON, and the ADON stated the status was not updated in the system. The DON stated the expectation was to verify signatures before updating code status and to upload the completed DNR immediately once finalized.

Penalty

Inspection fine: $13,065

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents reviewed for infection control. During observation, MA D used the same automated blood pressure cuff on Resident #52, Resident #17, and Resident #98 during medication pass without sanitizing the cuff between residents. The report states that MA D returned the cuff to the medication cart after each use and performed hand sanitization, but did not sanitize the cuff itself between resident uses. Resident #52 was a [AGE]-year-old resident admitted to the facility on 10/30/24 with diagnoses including dementia, hypertension, stroke, heart failure, anemia, and chronic kidney disease. The resident’s quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Resident #52 had an order for Med Pass 90 cc three times daily for supplement related to malnutrition, and the April 2026 MAR/TAR showed the supplement was given at 8:00 AM, 12:00 PM, and 4:00 PM. The care plan noted hypertension related to CHF and stroke, with blood pressure to be taken as ordered. Resident #17 was admitted on 04/10/26 with diagnoses including dementia, hypertension, diabetes, skin cancer, and hypertensive chronic kidney disease. The admission MDS showed a BIMS score of 13 out of 15. Resident #17 had orders for Amlodipine 10 mg daily and Carvedilol 3.25 mg twice daily, both held for SBP less than 110 and heart rate less than 60, and the April 2026 MAR/TAR showed both were due at 8:00 AM. Resident #98 was admitted on 04/20/26 with diagnoses including hemiplegia, diabetes, and heart failure; a nursing skilled evaluation note described the resident as alert and oriented x 3 with clear speech. Resident #98 had orders for Carvedilol 25 mg twice daily and Lasix 40 mg twice daily, with the April 2026 MAR/TAR showing administration at 8:00 AM and 4:00 PM. The DON stated she expected nursing staff to clean and sanitize the blood pressure cuff and monitor between each resident use for infection control.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications as ordered by physicians for two residents. For one resident with moderately impaired cognition, Type 2 diabetes, hypertension, chronic kidney disease, and insomnia, a physician’s order dated 3/12/2026 directed administration of melatonin 3 mg orally at bedtime, two hours before bedtime, for insomnia. Review of the March 2026 MAR showed blank entries for this melatonin dose on four consecutive days, and review of nursing notes for the same dates revealed no documented reasons for the blanks, despite facility policy requiring documentation of all medication administrations and reasons for any doses withheld, not administered, or refused. For a second resident, cognitively intact and diagnosed with multiple conditions including hyperlipidemia, dementia, acute chronic diastolic heart failure, hypothyroidism, atrial fibrillation, protein caloric malnutrition, allergy, anxiety, Type 2 diabetes, neuropathy, drug-induced subacute dyskinesia, hypertension, DVT, and insomnia, physician orders were in place for several medications, including aspirin for DVT prophylaxis, Austedo XR for drug-induced subacute dyskinesia, Claritin and fluticasone for allergy-related conditions, and furosemide for heart failure. The survey findings state that the facility failed to ensure this resident received medications as ordered by the physician. The facility’s own medication administration policy, dated April 2007, requires that medication administration be documented immediately after administration and that reasons for any withheld, not administered, or refused medications be recorded, but the report indicates this was not done for the residents reviewed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food storage, preparation, and dish sanitization in the kitchen, as observed during a survey. In the dry storage area, a bag of pasta noodles was found open and exposed to air, and a box of food thickener powder was left open and placed directly on the floor. Staff interviews confirmed that food items were expected to be sealed, labeled, dated, and stored at least six inches off the floor, but these practices were not consistently followed. The dietary manager acknowledged responsibility for monitoring food storage but admitted to overlooking the open pasta and the thickener on the floor during his rounds. Dishwashing procedures also failed to meet required standards. The high heat sanitizing dish machine was observed operating below the required temperatures, with the wash cycle at 130 degrees Fahrenheit and the sanitizing cycle at 152 and 169 degrees Fahrenheit during multiple checks, instead of the required 150 and 180 degrees Fahrenheit, respectively. Staff members were aware of the correct temperature requirements but did not consistently verify machine temperatures before use. One dietary aide admitted to considering dishes clean even when processed at substandard temperatures, and staff sometimes ran the machine multiple times to reach the correct temperature, contrary to policy. Interviews with the registered dietitian and administrative staff revealed uncertainty about responsibilities for food storage oversight and dish machine operation. The registered dietitian was not fully aware of the dish machine temperature requirements and had limited oversight hours in the kitchen. Facility policies and FDA Food Code requirements reviewed during the survey confirmed the need for proper food storage and dish sanitization practices, which were not consistently implemented, leading to the cited deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to hand hygiene protocols during meal tray distribution. Observations revealed that a CNA did not sanitize her hands after delivering meal trays to several residents, nor after touching her own clothing, and continued to handle food and resident items without performing hand hygiene. Another CNA was observed failing to perform hand hygiene between resident rooms while passing lunch trays, despite having received training on infection control and acknowledging the importance of hand hygiene to prevent cross-contamination. Additionally, the Dietary Manager (DM) was observed distributing meal trays, hugging, fist bumping, and shaking hands with residents without conducting hand hygiene between these interactions. Interviews with the DM and other staff confirmed that infection control training had been provided, and that facility policy required hand hygiene before and after resident contact, as well as between each resident when passing meal trays. Despite this, the DM did not follow these protocols during the observed meal service. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator confirmed that all staff were expected to follow hand hygiene protocols, and that monitoring and training were in place. Facility policies reviewed indicated clear expectations for hand hygiene before and after resident contact, after touching resident environments, and when handling food. However, the lack of adherence to these protocols by multiple staff members during meal service constituted a failure to implement the infection prevention and control program as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident was not served her lunch tray at the same time as her tablemate in the dining room. Observations showed that while one resident at the table received her meal, the other resident had to wait, with staff passing trays to other tables before serving her. The resident expressed that she often had to wait for her meal and felt uncomfortable when her tray was delayed, especially when her tablemate had already finished eating by the time she received her food. The resident involved had multiple medical diagnoses, including heart failure, type 2 diabetes with complications, hypertension, stroke, convulsions, lack of coordination, anxiety, and depression. Her care plan included monitoring eating habits due to unplanned weight gain, but she was independent with eating. The delay in meal service was attributed to her not being included on the list of residents eating in the dining room, which resulted in her tray being placed with the hall trays instead of being served with her tablemate. Interviews with staff, including the dietary manager, CNA, DON, and ADM, revealed that the facility's practice was to serve all residents at the same table simultaneously. However, there was no formal written policy for meal tray service in the dining room. Staff acknowledged that failing to serve residents together could make them feel left out or upset and that it was the responsibility of nursing staff to ensure all residents at a table received their meals at the same time. The incident was linked to a lack of communication and monitoring regarding which residents were eating in the dining room.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain comfortable and safe temperatures between 71°F and 81°F for all 20 residents reviewed, leading to temperatures in some rooms dropping as low as 64°F. The facility's heating system was not functioning properly, and portable space heaters were used as a temporary solution. However, these heaters did not adjust to room temperatures, resulting in inconsistent heating and leaving some residents cold. Observations and temperature measurements revealed that several rooms had temperatures below the required range, with some as low as 61.5°F. Interviews with residents and staff highlighted the discomfort and potential risks associated with the low temperatures. Some residents reported feeling cold, while others were provided with space heaters or additional blankets to mitigate the issue. The facility's administrator acknowledged the outdated heating system and the lack of replacement parts, indicating that a complete system replacement was necessary but would take time. Despite efforts to provide temporary heating solutions, the facility's inability to maintain consistent and adequate room temperatures posed a risk to residents' health and comfort. The facility's records and staff interviews confirmed that temperatures were being monitored, and efforts were made to provide warm blankets and beverages to residents. However, the failure to maintain the required temperature range placed residents at risk of hypothermia and other health issues. The facility's management was aware of the potential harm caused by the low temperatures and had implemented monitoring procedures, but the underlying issue of the malfunctioning heating system remained unresolved.

Removal Plan

• The Medical Director was notified by the Executive Director.
• The Extreme Cold Procedure was reviewed by Executive Director, DON, Maintenance Director and Medical Director. The Cold Alert Procedure was reviewed by ED, DON, Maintenance Director and Medical Director, temperature was changed to 65F. The temperature was changed from 60F to 65F.
• Executive Director, DON and Maintenance Director were reeducated on regulations re: resident room comfortable temperature range and a Comfortable Room Temperature Policy was written by the Life Safety Resource. The education was provided by the Life Safety Resource.
• Room Temperatures were audited by Department Heads to identify rooms needing space heaters. [name of company] repaired the condensing loop system. They provided a quote for an upgrade. [name of company] is a licensed professional HVAC company. [name of company] is the company under contract to complete the current repairs. The repair timeline is dependent on parts availability, it could be 3-4 weeks. The facility is planning on upgrading to PTAC units starting in Spring.
• Space heaters provided to all residents who agreed to have it. Space Heaters are monitored during room temperature checks or rounds by Nursing Staff/ Maintenance. Maintenance Director is responsible for the oversight of the space heaters.
• Commercial grade heaters have been located and are being placed on hallways to maintain temperatures per regulation. Upon completion of HVAC contractors, heaters will be removed. While heaters are in place, ongoing monitoring of temps and safety will be completed by walking rounds by Maintenance personnel or trained designee.
• Room temperatures will be audited every 2 hours by CNAs/ Maintenance. The Maintenance Director will be notified when temperatures are below 71. The Executive Director will be notified if room temperatures are below 65 and remain below 65 for one hour. Completion every 2 hours are until the temperatures are maintained >71, then, every shift during the inclement weather. If a room is less than 71F, Maintenance is to be notified; room temperature will be rechecked; nursing will offer the resident warm blankets and warm beverages; resident vital signs are being monitored at least twice per shift and the Charge Nurse will assess for change of condition as needed.
• All residents who prefer a cooler room temperature will be identified and their care plans updated. Residents are allowed to have cooler rooms within reason/based on their wishes/ resident rights. The Nursing staff will monitor the residents vital signs twice per shift and Charge Nurses will assess as indicated. Resident preference will be identified in the care profile.
• Residents will be offered warm blankets; warm beverages to prevent hypothermia. Nursing staff are monitoring resident during rounds and vital signs; Charge Nurses will assess as indicated.
• Windows were checked for air leaks by Maintenance Director.
• Portable AC Units were removed and windows sealed by Maintenance Director. (Unless resident declined the removal) The windows was closed which sealed itself, no other sealant was used. No resident was at a safety risk due to this action.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to ensure that a resident with pressure ulcers received appropriate treatment and care according to professional standards, the comprehensive care plan, and the resident's choices. The resident, an elderly female with a primary diagnosis of an upper arm fracture, was admitted to the facility with an open area on the right buttock. However, the facility did not obtain wound care orders for the resident's sacral wound upon admission and failed to document the implementation of these orders once they were obtained. The resident's medical records indicated that she was admitted with a stage 3 pressure ulcer on the right buttock, but there were no discharge orders for wound care from the hospital. The facility's staff, including the admitting nurse and the Assistant Director of Nursing (ADON), did not ensure that treatment orders were in place at the time of admission. The ADON did not complete a second skin assessment or obtain treatment orders until several days after admission, leading to a delay in treatment. This lack of timely care and documentation could have placed the resident at risk of wound deterioration. Interviews with facility staff, including the admitting nurse, ADON, and physicians, revealed a lack of communication and oversight in the wound care process. The facility's policy required that a second skin assessment be completed within 24 hours of admission and that all new admissions be audited the next business day to ensure accuracy and prevent delays in treatment. However, these procedures were not followed, resulting in a failure to provide adequate care for the resident's pressure ulcer.