A list of the most recent deficiencies for Willow Pass Healthcare Center. 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-21 | 2023-07-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-14 | 2022-12-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-14 | 2022-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-14 | 2022-12-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-10-14 | 2022-12-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-14 | 2022-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-14 | 2022-12-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-10-14 | 2022-12-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-14 | 2022-12-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-14 | 2022-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-14 | 2022-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-14 | 2022-12-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-14 | 2022-12-01 | 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 | 2022-10-14 | 2022-12-01 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-10-14 | 2022-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-14 | 2022-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-14 | 2022-12-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-14 | 2022-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-14 | 2022-12-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-10-14 | 2022-12-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-13 | 2022-11-25 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Use approved construction type or materials. | Fire Safety | 2022-10-18 | 2022-10-31 | 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 | 2022-10-18 | 2022-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-18 | 2022-10-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-21 | 2022-10-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-21 | 2022-10-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-05 | 2022-09-09 | Y |
| 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 | 2022-04-05 | 2022-08-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-07 | 2020-03-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-07 | 2020-03-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-07 | 2020-03-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-07 | 2020-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-07 | 2020-03-27 | 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 | 2020-02-07 | 2020-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-03-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-07 | 2020-03-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-07 | 2020-03-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-21 | 2020-03-23 | 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 | 2020-02-21 | 2020-03-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-21 | 2020-03-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-13 | 2019-04-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-01-09 | 2019-02-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-01-09 | 2019-02-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-09 | 2019-02-09 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-01-09 | 2019-02-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-01-09 | 2019-02-09 | N |
