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Deficiency Records for Willow Brook Christian Home
A list of the most recent deficiencies for Willow Brook Christian Home. 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 Willow Brook Christian Home. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2024-11-04 | 2024-12-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-11-04 | 2024-12-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-11-04 | 2024-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-11-04 | 2024-12-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-07 | 2024-12-20 | N |
| 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 | 2024-11-07 | 2024-12-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-11-07 | 2024-12-20 | 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 | 2024-11-07 | 2024-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-07 | 2024-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-07 | 2024-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-11-07 | 2024-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-11-07 | 2024-12-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-11-07 | 2024-12-20 | 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 | 2024-11-07 | 2024-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-11-07 | 2024-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-11-07 | 2024-12-20 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-05-26 | 2023-06-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-28 | 2022-04-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-28 | 2022-04-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-28 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-28 | 2022-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-28 | 2022-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-04-07 | N |
| 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 | 2022-02-22 | 2022-04-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-09-05 | 2019-09-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-05 | 2019-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-05 | 2019-09-24 | N |
| Post nurse staffing information every day. | Health | 2019-09-05 | 2019-09-24 | 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 | 2019-09-05 | 2019-09-24 | 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 | 2019-09-05 | 2019-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
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