Deficiency Records for Champions Healthcare at Willowbrook
Updated as of April 01, 2022
This is not the most recent data for Champions Healthcare at Willowbrook. For the most recent information, click here.
A list of the most recent deficiencies for Champions Healthcare at Willowbrook. 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? |
---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-10 | 2021-10-08 | 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 | 2021-09-10 | 2021-10-08 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
Provide and implement an infection prevention and control program. | Health | 2020-12-02 | 2021-01-06 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-11 | 2019-09-27 | Y |
Provide and implement an infection prevention and control program. | Health | 2019-09-11 | 2019-09-27 | Y |
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 | 2019-09-11 | 2019-09-16 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-15 | 2019-09-06 | 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 | 2019-08-15 | 2019-09-06 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-15 | 2019-09-06 | N |
Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-06 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-02 | 2019-05-14 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-05-14 | Y |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-09-13 | 2018-10-05 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-13 | 2018-10-05 | N |
Ensure that residents are free from significant medication errors. | Health | 2018-09-13 | 2018-10-05 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-13 | 2018-10-05 | 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 | 2018-09-13 | 2018-10-03 | 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 | 2018-09-13 | 2018-10-03 | N |
Provide properly protected cooking facilities. | Fire Safety | 2018-09-13 | 2018-10-03 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-13 | 2018-10-03 | N |