Cherith Care Center At Willow Brook

Based on review of the payroll based journal (PBJ), staff interviews and record review, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours, seven days a week. This had the potential to affect all facility residents. Facility census 30. Findings include Review of the PBJ report from the review period of 10/01/24 to 12/31/24 revealed the facility triggered for no RN for at least eight hours a day, seven days per week. Review of the registered nurse schedule for October 2024 revealed on 10/05/24, 10/06/24, 10/19/24, and 10/20/24 the facility had no RN working in the nursing home. Review of the registered nurse schedule for November 2024 revealed on 11/02/24, 11/03/24, 11/16/24, 11/17/24 and 11/30/24 had no RN working in the nursing home. Review of the registered nurse schedule for December 2024 revealed on 12/01/24, 12/14/24, 12/15/24, and 12/29/24 the facility had no RN working in the nursing home. Interviews on 05/22/25 from 1:00 P.M. to 3:30 P.M. with the Administrator and Minimum Data Set (MDS) Nurse #389 confirmed the information provided…

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, interview and policy review the facility failed to include all required information on the skilled nursing advanced beneficiary notice (ABN). This deficient practice affected two (Resident #14 and Resident #238) of three residents reviewed for cut letters. The facility census was 40. Finding include: 1. Review of the medical record for Resident #238 revealed an admission date of 02/16/2025. Diagnoses included dementia, difficulty walking, chronic kidney disease, adult failure to thrive, dementia, pressure ulcer of the sacral region, abnormal weight loss, encephalopathy, cognitive communication deficit, and Parkinson's disease. Review of the Skilled Nursing Facility ABN for Resident #238 revealed Beginning on (no date written), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Interview on 05/22/2025 at 2:25 P.M. with Social Worker (SW) #360 confirmed the missing date on the ABN form for Resident #238. SW#360 confirmed that the ABN form should be filled out completely when providing them to residents…

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, interview, observation and policy review the facility failed to ensure physician ordered wound treatments were in place to promote wound healing This affected one (Resident #9) of one residents reviewed for pressure ulcers. The facility census was 40. Finding include: Review of the medical record for Resident #9 revealed an admission date of 02/10/2018. Diagnoses included dementia, chronic kidney disease stage 2, cirrhosis of the liver, malignant neoplasm of the breast, urinary incontinence, Alzheimer's disease, anorexia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss. Review of wound- weekly observation tool for Resident #9 dated 04/16/2025 revealed a suspected deep tissue injury (SDTI) (a localized area of discolored, intact skin or a blood-filled blister caused by damage to the underlying soft tissue, typically from pressure or sheer) on the resident's sacrum. Review of wound- weekly observation tool for Resident #9 dated 05/19/2025 revealed the continued presence of SDTI on the resident's sacrum. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy and facility assessment review the facility failed to prevent Resident #88 from exiting the facility unsupervised and failed to complete a comprehensive assessment and thorough investigation following the incident. This affected one resident (Resident #88) of three residents reviewed for accidents. Findings include: Review of the medical record revealed Resident #88 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes, atherosclerotic heart disease, hyperlipidemia, mood disorder, benign prostatic hyperplasia, history of transient ischemic accident, and traumatic subdural hemorrhage. Review of hospital records (prior to admission) dated 04/21/25 revealed the resident had Parkinson's Disease with increased forgetfulness which was concerning with dementia. The resident had been placed on delirium precautions in the hospital. The wandering risk assessment dated [DATE] revealed Resident #88 was at low risk for…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of standing orders, and interview, the facility failed to ensure the facility bowel protocol for constipation was followed for Resident #14 and Resident #24. This affected two (Resident #14 and #24) three reviewed for bowel and bladder. Facility census was 30. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE] with diagnosis that included osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. A plan of care dated 03/18/25 revealed Resident #14 was a risk for constipation due to decreased mobility and medication use. Interventions included to follow facility bowel protocol for bowel management, milk of magnesia (laxative) as needed if no bowel movement in three days, monitor bowel movements every shift, and record bowel movement pattern each day. A significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had cognitive impairment and was frequently incontinent of bowel and…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a rationale was provided when a gradual dose reduction for psychotropic medications was contraindicated for Resident #24. This affected one (Resident #24) of five residents reviewed for unnecessary medications. Facility census was 30. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder. Pharmacy recommendations dated 09/23/24 revealed Resident #24 had been receiving Zoloft (antidepressant) 100 milligram (mg) daily, mirtazapine (antidepressant) 7.5 mg daily, and hydroxyzine (antihistamine also used for anxiety) 25 mg daily without a gradual dose reduction (GDR). Pharmacy asked if a GDR could be attempted in order to be sure Resident #24 was using the minimum effective dose. If a GDR was not warranted, a statement needed to be included explaining why a GDR would be…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the incident and accident log, interview and policy review the facility failed to maintain complete and accurate medical records related to resident incidents. This affected one resident (Resident #14) of three residents reviewed for accidents. The facility census was 30. Findings include: Review of the medical revealed Resident #14 was admitted on [DATE] with diagnosis that included osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. Review of the incident and accident log revealed on 04/02/25 at 12:00 A.M. a Certified Nursing Assistant (CNA) reported Resident #14 was on the floor. Resident #14 was found sitting on the floor in front of her recliner. The CNA stated Resident #14 was sliding out of the recliner when the CNA attempted to reposition Resident #14 but Resident #14 slid out of the chair onto the floor. A new intervention for a non-slip material was to be placed in the recliner. The Committee Review of Incidents dated…

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, interview, and policy review the facility failed to obtain resident or resident representative consent and provide education prior to administration of the influenza vaccination. This affected three resident residents (Resident #9, #10 and #20) of five residents reviewed for vaccinations. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/10/2018. Diagnoses included dementia, atherosclerotic hear disease of native coronary artery, chronic kidney disease stage 2, cirrhosis of the liver, malignant neoplasm of the breast, Alzheimer's disease, anorexia, dysphagia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss. Review of Resident #9's influenza vaccination 2024 records revealed an inoculation date of 09/17/2024. Further review of the medical record revealed no influenza consent or vaccine information/education was provided Interview on 05/22/2025 at 11:50 A.M. with Minimum Data Set (MDS) Coordinator #389 confirmed the facility gave Resident #9 an influenza vaccination on…

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 observations, staff interview and review of the facility policy, the facility failed to ensure safe and sanitary food storage in the refrigerator and freezer in the main kitchen area. This had the potential to affect all 31 residents residing in the facility who received food from the kitchen. Findings include: Observations on 05/01/23 at 9:56 A.M. of the kitchen revealed a cup of creamer or milk left uncovered and had spilled on a tray in the refrigerator; a pre-made plate of sausage with peppers and onions was left undated in the refrigerator; coconut shrimp was in an individually sized portioned zip lock bag and was left open to air in the freezer; a pack of veggie burgers were left open to air in the freezer; a bag of rice was on top of a container with rice bags inside of it. The individual bag was undated; a metal container of hot dogs were left uncovered and open to air in the freezer; a bag of fries was undated and had a hole with food coming out of the hole in the freezer; two pies were left on a rack in the walkway of the kitchen undated and uncovered open to air;…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure pharmacy recommendations were followed up and implemented timely. This affected three (Residents #14, #20 and #25) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include 1. Review of the medical record for Resident #20 revealed an admission date of 12/20/21. Diagnoses included gastroesophageal reflux disease (GERD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment. Review of the physician orders for Famotidine (treats GERD) revealed from 01/14/222 to 04/28/23, Famotidine was to be administered at 40 milligrams (mg) tablet daily. On 04/28/23, the order for Famotidine was changed to 20 mg tablet daily. Review of the monthly pharmacy recommendation dated 03/21/22 revealed it was reviewed by the physician on 03/24/22. The recommendation was for Famotidine 40 mg once daily to be decreased to 20 mg…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the facility policy, the facility failed to have a medication error rate less than five percent. There were two medication errors out of 26 opportunities resulting an a 7.69 percent (%) medication error rate. This affected two (Resident #14 and #19) of four residents observed for medication administration. The facility census was 31. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included supraventricular tachycardia, age related osteoporosis, and dementia with severe agitation. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was severely cognitively impaired, had no delusions, hallucinations, or behaviors documented. Review of Resident #19's physician orders revealed an order for Oyster Shell Calcium (supplement) 500 milligram (mg) - five micrograms (mcg) with Vitamin D twice daily. Observation of medications…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the facility policy, the facility failed to administer insulin correctly to a resident, resulting in a resulting in a significant medication error. This affected one (Resident #14) of four residents observed for medication administration. The facility census was 31. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, atrial fibrillation, and diabetes mellitus (DM). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact, had a diagnosis of DM, and received insulin. Observation of Resident #14 receiving medications from Licensed Practical Nurse (LPN) #601 on 05/02/23 at 11:48 A.M. revealed the resident received Novolog insulin five units via a delivery pen, and Oxybutynin (anticholinergic) five milligrams (mg) orally. LPN #601 was observed to dial the Novolog pen to five units and administer…

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 medical record review, staff interview and policy review, the facility failed to ensure code status's in the electronic medical record were accurate. This affected two (#2 and #14) of 16 residents reviewed during the survey. The census was 31. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 11/19/18 with diagnoses including irritable bowel syndrome, depression, and diabetes mellitus type two. Review of the electronic medical record revealed a physician's order dated 02/05/19 for Do Not Resuscitate (DNR) comfort care arrest. Review of the medical record for Resident #2 revealed a signed DNR Form dated 03/19/19 for Resident #2's code status to be DNR comfort care. Interview with Director of Nursing on 10/16/19 at 3:05 P.M. verified Resident #2's code status in the electronic medical record did not match the signed DNR form dated 03/19/19. 2. Review of the medical record for Resident #14 revealed an admission date of 10/16/18 with diagnoses including Parkinson's disease, depression, and hypertension. Review of the electronic…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to update care plan interventions following a resident fall. This affected two (#9 and #79) of two residents reviewed for accidents. Facility census was 31. Findings include 1. Review of medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included vertebral fracture of thoracic vertebrae 11 and 12, brain cancer, hypertension, and history of falling. Review of the comprehensive assessment dated revealed 10/02/19 revealed the resident had moderate cognitive impairment. Resident #79 required partial to moderate assistance for sit to stand, toilet transfers, and bed to chair transfers. Review of the comprehensive assessment dated [DATE] revealed Resident #79 had a history of falls prior to admission, one of which resulted in a fracture. The resident had fallen since admission and received an injury (not a major injury). Review of progress notes revealed on 09/23/19 Resident #79 was washing…

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.