Deficiency Records for Brickyard Healthcare - Willow Springs Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Brickyard Healthcare - Willow Springs Care Center. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-13 | 2024-01-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-31 | 2023-09-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-12 | 2023-06-26 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-06-12 | 2023-06-26 | Y |
| Meet other general requirements. | Fire Safety | 2023-04-11 | 2023-05-02 | 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 | 2023-04-11 | 2023-05-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-11 | 2023-05-02 | 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 | 2023-03-27 | 2023-04-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-27 | 2023-04-24 | 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 | 2023-03-27 | 2023-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-27 | 2023-04-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-27 | 2023-04-24 | 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 | 2023-01-10 | 2023-02-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-17 | 2022-09-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-17 | 2022-09-13 | 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 | 2022-05-19 | 2022-07-18 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-19 | 2022-07-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-19 | 2022-06-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-19 | 2022-06-13 | N |
| Develop a communication plan. | Fire Safety | 2022-05-19 | 2022-06-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-19 | 2022-06-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-19 | 2022-06-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-25 | 2022-05-31 | 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 | 2022-04-25 | 2022-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-25 | 2022-05-31 | 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 | 2022-04-25 | 2022-05-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-04-25 | 2022-05-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-25 | 2022-05-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-25 | 2022-05-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-25 | 2022-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-05-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-05 | 2022-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-05 | 2022-01-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-12 | 2021-08-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-13 | 2021-06-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-13 | 2021-06-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-13 | 2021-06-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Develop a communication plan. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-16 | 2020-01-13 | 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 | 2019-12-16 | 2020-01-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-16 | 2020-01-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-25 | 2019-10-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-09-25 | 2019-10-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-25 | 2019-10-22 | 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 | 2019-09-25 | 2019-10-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-25 | 2019-10-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-25 | 2019-10-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-25 | 2019-10-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-09-25 | 2019-10-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-25 | 2019-10-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-25 | 2019-10-22 | 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 | 2019-09-25 | 2019-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-13 | Not Fixed | Y |
