Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
40 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Dec 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and investigate an injury of unknown origin sustained by Resident #44.
Findings
The facility failed to timely report and investigate a skin tear injury of unknown origin on Resident #44. The injury was identified on 09/03/25 but was not reported to the state agency until 09/11/25 after family concerns. The investigation found no evidence of abuse or mistreatment, but the delay in reporting and investigation was noted as non-compliance.
Complaint Details
Complaint Number 2627023 investigated the facility's failure to timely report and investigate an injury of unknown origin affecting Resident #44. The injury was a skin tear/laceration found on 09/03/25, with delayed reporting to the state agency until 09/11/25 after family concerns. The investigation found no evidence of abuse or mistreatment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely investigate an injury of unknown origin. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed with injuries: 3
Resident affected: 1
Facility census: 40
Skin tear size: 5.5
Skin tear width: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #200 | Registered Nurse | Named in delay of reporting injury and incomplete incident report |
| CNA #99 | Certified Nursing Aide | Observed skin tear after Hoyer transfer and reported to nurse |
| Director of Nursing | Director of Nursing (DON) | Verified disciplinary action for RN #200 and investigation details |
| Assistance Director of Nursing | Assistant Director of Nursing (ADON) | Updated incident report after investigation |
| Regional Administrator | Regional Administrator | Discussed investigation findings and injury cause |
| CNA #210 | Certified Nursing Aide | Reported no incident during transfer that would cause injury |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Sep 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to incidents involving mechanical lift transfers that resulted in resident injuries.
Findings
The facility failed to use appropriate slings for mechanical lifts and did not maintain the lifts per manufacturer's instructions, resulting in two residents sustaining injuries during transfers. One resident suffered multiple rib fractures after a sling broke, and another sustained a laceration from contact with the lift's swivel bar.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2566262.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to use appropriate slings for mechanical lifts and failure to maintain the mechanical lift per manufacturer's instructions resulting in resident injury. | Level of Harm - Actual harm |
Report Facts
Facility census: 48
Residents reviewed for falls: 3
Staples required: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #70 | Registered Nurse | Called into the room after Resident #4 fell during mechanical lift transfer. |
| Certified Nursing Assistant #72 | Certified Nursing Assistant | Involved in transferring Resident #4 with the wrong sling that broke. |
| Certified Nursing Assistant #62 | Certified Nursing Assistant | Involved in transferring Resident #1 and moving the mechanical lift when the resident was struck. |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed details of both incidents and interventions implemented. |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 12
Nov 7, 2024
Visit Reason
The inspection was conducted as an annual survey of Willow Brook Christian Home to assess compliance with regulatory requirements across multiple areas including resident rights, care planning, medication management, infection control, and safety.
Findings
The facility was found deficient in several areas including failure to ensure residents' rights to dignity and safe environment, incomplete care plans, inadequate monitoring of physical restraints, failure to provide written bed-hold notices, improper medication administration and monitoring, insufficient documentation of nutritional supplement intake, unsafe storage of oxygen tanks, improper infection control practices with glucometers, and failure to follow antibiotic stewardship guidelines.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure all residents received dignified choices to remain in their room, affecting Resident #300. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a comfortable, homelike environment due to disorderly storage of incontinence briefs in Resident #35's bathroom. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document ongoing assessments to evaluate the need for physical restraints affecting Residents #28 and #300. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written bed-hold notice to Resident #25 or representative upon hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plans addressing all resident needs for Residents #10, #12, #15, #34, and #41. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dressing changes for a skin tear were completed as ordered for Resident #34. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe storage of portable oxygen tanks in Resident #38's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document nutritional supplement intake and complete annual nutrition assessments for Residents #25, #36, and #41. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor for side effects of anticoagulant use and follow medication administration parameters for Residents #25 and #33. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately identify and monitor targeted behaviors for Resident #15 using psychotropic medication Zoloft. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly clean and disinfect glucometer between uses, risking cross-contamination for Residents #9, #297, and #25. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow antibiotic stewardship program guidelines for appropriate antibiotic use for Residents #33 and #101. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 45
Incontinence briefs: 11
Weight loss percentage: 5.5
Bed-hold rate: 373
Sotalol doses administered outside parameters: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Noted Resident #300 needed monitoring outside room; confirmed no restraint assessments done |
| Certified Nursing Assistant #157 | CNA | Reported on Resident #300 and #35 care and environment |
| Director of Nursing | DON | Confirmed restraint assessment practices, medication administration issues, and infection control deficiencies |
| MDS Nurse #113 | MDS Nurse | Confirmed lack of care plans for psychotropic medication and other care plan deficiencies |
| Registered Nurse #117 | RN | Observed glucometer use and confirmed lack of sanitization |
| Licensed Practical Nurse #129 | LPN | Confirmed wound care and UTI notification procedures |
| Dietitian #180 | Dietitian | Confirmed lack of nutritional assessments and documentation |
| Administrator | Administrator | Confirmed lack of documentation for anticoagulant monitoring |
| Assistant Director of Nursing #115 | ADON | Confirmed antibiotic stewardship and monitoring deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the employment of a nurse without a valid state license.
Findings
The facility failed to ensure that a Licensed Practical Nurse (LPN #59) had a valid nursing license. The nurse worked from January 2021 until May 7, 2023 without a current license, which was discovered after a complaint was made to the Board of Nursing.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00142799.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Employ staff that are licensed, certified, or registered in accordance with state laws; facility failed to ensure a nurse had a valid license. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of nurses affected: 1
Number of nurses in long term care: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #59 | Licensed Practical Nurse | Employed without a valid state license from January 2021 to May 7, 2023. |
| Human Resource Staff #60 | Interviewed regarding license verification process and knowledge of LPN #59's temporary license. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about license checks and oversight related to LPN #59. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Conducted license check on LPN #59 in February but did not read the report. |
| Administrator | Administrator | Stated that LPN #59 had been employed without a valid nursing license. |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 6
Feb 28, 2022
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements including resident care, abuse reporting, assessments, medication administration, infection control, and skin integrity monitoring.
Findings
The facility was found deficient in timely reporting of suspected abuse, accurate resident assessments, PASARR screening, monitoring of skin impairments and edema, medication error rates exceeding 5%, and failure to implement a Legionella prevention plan according to the water management program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to timely notify the Administrator and state agency of an alleged incident of abuse/neglect affecting one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately reflect resident wounds in assessments for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a Preadmission Screening and Resident Review (PASARR) timely for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor residents' skin impairments and edema for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rate was less than 5%, with three medication errors out of 33 opportunities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Legionella prevention plan according to the facility water management plan. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 44
Medication error rate: 9.09
Medication errors: 3
Medication administration opportunities: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #117 | Registered Nurse | Administered medication with incomplete order |
| RN #112 | Registered Nurse | Held medication incorrectly based on blood pressure; involved in skin monitoring |
| RN #110 | Registered Nurse | Administered eye drops incorrectly; involved in skin monitoring |
| STNA #132 | State Tested Nurse Assistant | Interviewed regarding abuse allegation |
| STNA #138 | State Tested Nurse Assistant | Mentioned in abuse allegation investigation |
| Social Worker #179 | Social Worker | Interviewed regarding PASARR completion |
| Director of Nursing | Director of Nursing | Interviewed regarding skin assessments and bruise monitoring |
| Maintenance Director #188 | Maintenance Director | Interviewed regarding Legionella prevention plan implementation |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Sep 5, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care plans, staffing, medication management, and hospice services.
Findings
The facility was found deficient in multiple areas including inadequate insurance coverage for resident personal funds, delayed baseline care plans, incomplete comprehensive care plans for residents with specific needs, inaccurate nurse staffing postings, failure to monitor psychotropic medication use properly, and lack of hospice documentation for residents receiving hospice care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Potential for minimal harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure resident personal care needs accounts were insured for the balance of all resident funds. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure baseline care plans were completed within 48 hours and provided to the resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement complete care plans with measurable objectives for residents with psychotropic medication use, multiple falls, and chronic conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post daily nurse staffing information with correct census and actual hours worked. | Level of Harm - Potential for minimal harm |
| Failed to assess and monitor the need for psychotropic medications and implement non-pharmacological interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain hospice services documentation in residents' charts as required by facility-hospice agreement. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 15
Personal care needs account balance: 5762.32
Surety bond amount: 5000
Surety bond amount: 10000
Facility census: 40
Residents reviewed for comprehensive care plans: 12
Residents affected by care plan deficiencies: 3
Facility census: 41
Facility census: 44
Facility census: 45
Residents reviewed for unnecessary medications: 5
Facility census: 40
Residents receiving hospice services: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #560 | Registered Nurse | Confirmed no assessment or interventions for insomnia in Resident #8 |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing census, medication monitoring, and care plan deficiencies |
| Minimum Data Set Coordinator #30 | MDS Coordinator | Verified baseline care plan delays and comprehensive care plan deficiencies |
| Registered Nurse #2 | Registered Nurse | Confirmed care plan not updated for Resident #9's cognitive changes |
| Hospice Supervisor #510 | Hospice Supervisor | Confirmed hospice progress notes were not left in the facility after visits |
| Administrator | Administrator | Confirmed number of residents with personal care needs accounts and surety bond details |
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