Willow Brook Christian Home

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Administration Deficiencies

Employ staff that are licensed, certified, or registered in accordance with state laws.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Egress Deficiencies

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.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

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.

Administration Deficiencies

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.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.