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? |
|---|---|---|---|---|
| Provide activities to meet all resident's needs. | Health | 2024-01-12 | 2024-01-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-11 | 2024-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-11 | 2024-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-11 | 2024-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-12 | 2024-01-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-12 | 2024-01-15 | 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 | 2024-01-12 | 2024-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-12 | 2024-01-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-11 | 2024-01-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-11 | 2024-01-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-11 | 2024-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-11 | 2024-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-17 | 2023-08-11 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-29 | 2022-12-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-12-01 | 2022-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-01 | 2022-12-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-01 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2022-12-16 | 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 | 2022-11-29 | 2022-12-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-13 | 2022-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-05-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-05-06 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-04-13 | 2022-05-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-30 | 2022-01-24 | Y |
| 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 |
