A list of the most recent deficiencies for Willowbrook Terrace. 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 all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-07 | 2023-12-08 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-07 | 2023-12-08 | Y |
Respond appropriately to all alleged violations. | Health | 2023-12-07 | 2023-12-08 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-07 | 2023-12-08 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-07 | 2023-12-08 | Y |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-07 | 2023-12-08 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-28 | 2022-02-18 | Y |
Respond appropriately to all alleged violations. | Health | 2022-01-28 | 2022-02-18 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-13 | 2020-01-10 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-13 | 2020-01-10 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-13 | 2020-01-10 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-01-10 | 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 | 2019-12-13 | 2020-01-10 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-13 | 2020-01-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-13 | 2020-01-10 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-13 | 2020-01-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-13 | 2020-01-10 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-10 | 2020-01-10 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-10 | 2020-01-10 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-28 | 2018-05-31 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-30 | 2018-05-11 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-03-30 | 2018-05-11 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-30 | 2018-05-11 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-03-30 | 2018-05-11 | 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 | 2018-03-30 | 2018-05-11 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-30 | 2018-05-11 | N |
Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Provide emergency officials' contact information. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-28 | 2018-05-11 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-28 | 2017-03-20 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-28 | 2017-03-20 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2017-01-28 | 2017-03-20 | N |
Give residents a notice of rights, rules, services and charges. | Health | 2017-01-30 | 2017-03-08 | N |
Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-01-30 | 2017-03-08 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-01-30 | 2017-03-08 | N |
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-01-30 | 2017-03-08 | N |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-01-30 | 2017-03-08 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-30 | 2017-03-08 | N |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-01-30 | 2017-03-08 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-30 | 2017-03-08 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-01-30 | 2017-03-08 | N |
Provide or obtain dental services for each resident. | Health | 2017-01-30 | 2017-03-08 | N |
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-01-30 | 2017-03-08 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-30 | 2017-03-08 | N |