Deficiency Records for Willowbrooke Ctskdcarectr Atnormandy Farms Estates
Updated as of April 01, 2024
A list of the most recent deficiencies for Willowbrooke Ctskdcarectr Atnormandy Farms Estates. 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 requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-07-26 | 2023-09-10 | 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 | 2023-07-26 | 2023-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-26 | 2023-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-07 | 2021-10-21 | Y |
| Meet other general requirements. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-08-18 | 2021-10-11 | 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 | 2021-08-18 | 2021-10-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-18 | 2021-10-11 | 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 | 2021-08-18 | 2021-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-13 | 2021-09-10 | 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 | 2021-08-13 | 2021-09-10 | 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 | 2021-08-13 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-13 | 2021-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-09-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-13 | 2021-09-10 | N |
