Deficiency Records for Willow Brooke Ct Skilled Care Ctr at Heron Point
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Brooke Ct Skilled Care Ctr at Heron Point. 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? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2019-05-21 | 2019-06-13 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-05-21 | 2019-06-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-21 | 2019-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-21 | 2019-06-13 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-04-09 | 2019-05-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-09 | 2019-05-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-09 | 2019-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-09 | 2019-05-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-09 | 2019-05-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-04-09 | 2019-05-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-09 | 2019-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-09 | 2019-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-09 | 2019-05-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-09 | 2019-05-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-09 | 2019-05-24 | 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 | 2019-04-09 | 2019-05-24 | 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 | 2019-04-09 | 2019-05-24 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-04-09 | 2019-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-09 | 2019-05-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-06 | 2018-01-31 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-06 | 2018-01-31 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-06 | 2018-01-31 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-06 | 2018-01-31 | N |
| Keep all essential equipment working safely. | Health | 2017-11-06 | 2018-01-31 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-11-06 | 2018-01-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-10-18 | 2017-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-18 | 2017-11-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-11-21 | 2017-01-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2016-11-21 | 2017-01-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-11-03 | 2016-11-30 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-03 | 2016-11-04 | N |
