A list of the most recent deficiencies for Willow Brook Christian Home. 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? |
|---|---|---|---|---|
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-05-26 | 2023-06-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-28 | 2022-04-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-28 | 2022-04-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-28 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-28 | 2022-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-28 | 2022-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-04-07 | N |
| 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 | 2022-02-22 | 2022-04-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-22 | 2022-04-07 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-09-05 | 2019-09-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-05 | 2019-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-05 | 2019-09-24 | N |
| Post nurse staffing information every day. | Health | 2019-09-05 | 2019-09-24 | 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 | 2019-09-05 | 2019-09-24 | N |
| 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. | Health | 2019-09-05 | 2019-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-05 | 2019-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-16 | 2018-09-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-08-16 | 2018-09-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-16 | 2018-09-18 | 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 | 2018-08-16 | 2018-09-18 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-08-16 | 2018-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-16 | 2018-09-18 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-08-14 | 2018-09-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-14 | 2018-09-18 | N |
