A list of the most recent deficiencies for Willowbrooke Court at Country House. 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? |
|---|---|---|---|---|
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-26 | 2022-06-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-15 | 2019-08-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-15 | 2019-08-30 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-07-15 | 2019-08-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-07-15 | 2019-08-30 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-07-15 | 2019-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-15 | 2019-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-15 | 2019-08-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-15 | 2019-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-15 | 2019-08-30 | 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 | 2019-07-15 | 2019-08-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-15 | 2019-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-15 | 2019-08-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-15 | 2019-08-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-15 | 2019-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-18 | 2018-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-18 | 2018-08-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-18 | 2018-08-14 | 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 | 2018-07-18 | 2018-08-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-18 | 2018-08-14 | 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 | 2018-07-18 | 2018-08-14 | N |
