Willowbrooke Court At Cokesbury Village

Based on interview, the facility failed to designate an onsite Infection Control Preventionist at the facility from 6/3/25 to 7/13/25. Findings include:7/28/25 1:30 pm - During an interview, E2 (DON) stated [E7] is working from home. I started on 7/14/25. I have a certification for Infection Prevention training.7/28/25 1:50 pm - During an interview, E7 (ADON, Infection Preventionist) stated, I have been working from home since 6/3/25. I will be back on 7/30/25.7/29/25 11:35 am - During an interview, E2 stated, I don't know that anyone was here between 6/3/25 and 7/13/25 that has an Infection Preventionist certification.7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on record review and interview, it was determined that for one (R5) out of five residents reviewed for infection control, the facility failed to offer and document pneumococcal immunization. Findings include: The facility policy dated 2023 and titled, COVID-19, Influenza, and Pneumococcal Education and Consent for Residents included, . Upon admission the licensed nurse will obtain consent from the resident or legal responsible party using the COVID-19, Influenza, or Pneumococcal Vaccine Consent Form. This form will then be stored in the residents' primary care electronic health record. An immunization history is documented and maintained for each resident in the electronic health record in the immunization section.7/8/25 - R5 was admitted to the facility with diagnoses including traumatic subarachnoid hemorrhage and anemia. 7/21/25 - A comprehensive MDS assessment documented R5 had a BIMS score of 14, indicating intact cognition.7/29/25 11:40 am - During an interview, E2 (DON) stated We don't have any vaccine documentation for [R5].7/29/25 2:00 pm - Findings were reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, one (R5) out of five residents reviewed for infection control, the facility failed to offer and document COVID-19 immunization. Findings include: The facility policy dated 2023 and titled, COVID-19, Influenza, and Pneumococcal Education and Consent for Residents included, . Upon admission, the licensed nurse will obtain consent from the resident, or legal responsible party, using the COVID-19, Influenza, or Pneumococcal Vaccine Consent Form. This form will then be stored in the residents' primary care electronic health record. An immunization history is documented and maintained for each resident in the electronic health record in the immunization section.7/8/25 - R5 was admitted to the facility with diagnoses including traumatic subarachnoid hemorrhage and anemia.7/21/25 - A comprehensive MDS assessment documented R5 had a BIMS score of 14, indicating intact cognition.7/29/25 11:40 am - During an interview, E2 (DON) stated We don't have any vaccine documentation for [R5].7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for two (E5 and E6) out of ten employees reviewed for training, the facility failed to have records of abuse, neglect and exploitation training for the contracted employees. Findings include: 7/28/25 11:30 AM- During the review of the staff training worksheet, E1 (NHA) stated that she did not have any documentation of E5 (NP) and E6 (MD)'s abuse, neglect and exploitation training. E1 stated that the facility did not keep a file on the consultant employees and relied on their companies to supply that information. She stated that she had reached out to each consultant's [medical practice] and requested that they send over the documentation of his abuse/neglect/exploitation training. 7/29/25 10:45 AM - During an interview, E1 stated that she had not received any documentation regarding E5 or E6's training for abuse, neglect and exploitation.7/29/25 2:00PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 8/28/24 9:30 AM thru 9:45 AM - An initial observation of the facility kitchen revealed the following: -Dry food storage area: uncovered graham cracker crumbs. -Walk in refrigerator: unlabeled pies, a large unlabeled casserole, uncovered potatoes and carrots. -Walk in freezer: an unidentified frozen portion of meat was stored in the freezer. Additionally, the gasket to the freezer was not completely sealed, which allowed outside air to flow into the freezer and caused ice to buildup on the floor and shelving at the entrance to the freezer. -Environment: the paint was peeling from the wall in the chemical storage area. 8/28/24 12:30 PM - A cooling fan in use in the dish washing area was noted to have dust and debris. The wall positioned to the right side of the fan also contained dust and debris. 9/3/24 2:00 PM - Findings were reviewed with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for two (R1and R109) out of three residents reviewed for infection control, the facility failed to establish and maintain an infection control program using enhanced barrier precautions. For R1, the presence of an indwelling feeding tube was criteria for Enhanced Barrier Precautions (EBP). R109 was admitted with PICC (percutaneously inserted central catheter) line and was diagnosed as colonized with enterococcus faecium VRE; both of which are criteria for EBP. Also the facility line listing did not specify the name of the pathogen. Findings include: As per CDC (Centers for Disease Control and Prevention) definition (6/28/24), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R1) out of two residents reviewed for medications, the facility failed to ensure that the admission pharmacy review of medications identified the correct route of medication administration. Findings include: Review of R1's clinical record revealed: A review of a facility policy titled Resident Health Services Manual, Policies and Procedures, Subject: Drug Regimen Review, revised 2/19 revealed: Policy: . Drug Regimen Review Includes: .A review of the drug regimen to identify, and if possible, to prevent potentially clinically significant medication adverse consequences. Clinically significant medication issues may include, but are not limited to: . Medication dose, frequency, route, or duration not consistent with resident's condition . 8/16/24 - R1 was admitted to the facility directly from a hospitalization after an acute stroke. R1's hospital discharge records revealed that R1 now had swallowing difficulties resulting from the stroke and that R1 was not to have anything by mouth because R1 could not swallow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined that the facility failed to ensure that food was stored and prepared in a sanitary manner. Findings include: The initial kitchen tour on 9/28/23 from 9:00 AM - 9:45 AM revealed that two moldy boxes of strawberries were found in the walk-in refrigerator. 10/3/23 2:44 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (ED) and E5 (DAL).

Based on record review, observation, and interviews, it was determined that for one (R4) out of one resident reviewed for dialysis, the facility failed to ensure that R4's admission physician's orders dated 8/8/23 included hemodialysis treatments for Tuesday, Thursday and Saturday. Findings include: 8/8/23 - R4 was admitted to the facility with diagnoses including but limited to: atrial fibrillation (irregular heart rhythm that increases risk for blood clots) and chronic kidney disease (stage 5) with R4 being dependent on renal dialysis. 8/9/23 - R4 was care planned for hemodialysis with interventions including; encourage me to go to my scheduled dialysis appointments and monitor for dressing site on my right chest wall. Dressing is changed at dialysis. 9/28/23 11:15 AM - This surveyor observed R4's bed was empty and was unable to find R4. During an interview, E6 (LPN) stated that R4 was at his hemodialysis appointment and usually arrives back at the facility around 4:30 PM. 9/29/23 9:14 AM - During an interview, R4 confirmed that he leaves the facility to go to an off-site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R307) out of three (3) residents sampled for the use of Unnecessary Medications, the facility failed to ensure that R307 received adequate monitoring for the use of a psychoactive medication. Findings include: 9/23/23 - R307 was admitted to the facility with diagnoses including but not limited to atrial fibrillation (irregular heart rhythm that increases risk for blood clots), vascular dementia without behavioral, psychotic or mood disturbance, and walking difficulty. 9/24/23 - E7 (NP) ordered Trazadone 150 mg (antidepressant) and melatonin 3 mg (sleep aid) daily at bedtime for the diagnosis of insomnia. 9/24/23 - R307's care plan documented, I use the psychotropic medication Trazadone (antidepressant) related to my insomnia. The goals included but not limited to, .remain free of psychotropic drug related complications, including movement disorder, discomfort, low blood pressure . The interventions included administer the psychotropic medications as ordered and monitor for side effects and effectiveness every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R4) out of three residents reviewed for Unnecessary Medications, the facility failed to ensure that R4's medical record met with accepted professional standards and practices with regards to the anticoagulation order. Findings include: 8/8/23 - R4 was admitted to the facility with diagnoses including but limited to: atrial fibrillation (irregular heart rhythm that increases the risk for blood clots) and chronic kidney disease (stage 5) with R4 being dependent on renal dialysis. 8/8/23 - R4's electronic medical record (EMR) documented a verbal order from E7 (Nurse Practitioner) for Eliquis oral tablet 5 mg (milligrams) (Apixiban)- give one tablet by mouth two times a day for anticoagulation (the process of preventing the clotting of blood). Anticoagulation is not a medical diagnosis; it is a physiologic state. The medical diagnosis, which required that R4 be in a state of anticoagulation, was R4's diagnosis of atrial fibrillation. Therefore, atrial fibrillation should have been the medical diagnosis for the use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.