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Deficiency Records for Willowbrook Manor
A list of the most recent deficiencies for Willowbrook Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Willowbrook Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-04 | 2024-07-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-04 | 2024-07-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-04 | 2024-07-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-04 | 2024-07-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-04 | 2024-07-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-04 | 2024-07-02 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-04 | 2024-07-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-04 | 2024-07-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-04 | 2024-07-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-04 | 2024-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-04 | 2024-07-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-06-04 | 2024-07-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-30 | 2024-07-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-30 | 2024-07-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-30 | 2024-07-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-23 | 2024-06-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-23 | 2024-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-23 | 2024-06-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-20 | 2024-01-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-20 | 2024-01-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-11-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-06-16 | 2023-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-08-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-16 | 2023-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-16 | 2023-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-08-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-16 | 2023-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-16 | 2023-08-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-16 | 2023-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-16 | 2023-08-01 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-16 | 2023-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-16 | 2023-08-01 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-15 | 2023-02-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-28 | 2022-12-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-28 | 2022-12-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-28 | 2022-12-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-27 | 2022-07-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-27 | 2022-07-26 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-11-24 | 2021-12-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-24 | 2021-12-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-11-24 | 2021-12-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-05 | 2021-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-05 | 2021-09-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-05 | 2021-09-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-08-05 | 2021-09-08 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-05 | 2021-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-05 | 2021-09-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-28 | 2021-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-09-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-28 | 2021-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-28 | 2021-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-09-08 | N |
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