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Deficiency Records for Willowbrook Post Acute
A list of the most recent deficiencies for Willowbrook Post Acute. 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 Post Acute. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-17 | 2024-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-17 | 2024-06-20 | 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 | 2024-05-17 | 2024-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-17 | 2024-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-17 | 2024-06-20 | 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 | 2024-05-17 | 2024-06-20 | 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 | 2024-05-17 | 2024-06-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-17 | 2024-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-17 | 2024-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-06-20 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-14 | 2024-06-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-14 | 2024-06-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-07 | 2023-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-07 | 2023-12-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-07 | 2023-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-07 | 2023-12-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-07 | 2023-12-08 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-07 | 2023-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-28 | 2022-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-28 | 2022-02-18 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-13 | 2020-01-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-13 | 2020-01-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-13 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-01-10 | 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 | 2019-12-13 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-13 | 2020-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-13 | 2020-01-10 | 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 | 2019-12-13 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-13 | 2020-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-10 | 2020-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-10 | 2020-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-28 | 2018-05-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-30 | 2018-05-11 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-28 | 2018-05-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
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