The incident at Willow Brook Christian Home was investigated following a complaint and resulted in a citation for actual harm, the inspection report shows.
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The violation was categorized at Scope/Severity Level D, meaning inspectors identified it as isolated in scope.
The violation was not isolated to one step in that process.
It was a short answer to a simple question, and it landed in the inspection record without elaboration.
Inspectors determined the facility was not meeting that standard.
The citation, issued August 29, 2025, covered a pattern of failures under the regulatory category that protects a resident's right to a homelike environment.
The violation fell under pharmacy service deficiencies.
Inspectors determined the facility had failed to properly provide and implement its infection prevention and control program.
The citation was one of eight deficiencies documented during the complaint inspection.
The citation was one of nine deficiencies inspectors documented during the complaint inspection.
The inspection was triggered by a complaint.
Not a mistake on one afternoon, in one room, with one person.