A list of the most recent deficiencies for Willow Tree Care 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-05 | 2022-12-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-05 | 2022-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-11-20 | 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 | 2022-10-19 | 2022-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-19 | 2022-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-19 | 2022-11-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-05 | 2022-11-09 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-10-05 | 2022-11-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-05 | 2022-11-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-05 | 2022-11-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-05 | 2022-11-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-05 | 2022-11-09 | 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 | 2022-10-05 | 2022-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-11-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-05 | 2022-11-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-05 | 2022-11-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-05 | 2022-11-09 | 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 | 2022-10-05 | 2022-11-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-10-05 | 2022-11-09 | 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 | 2022-10-05 | 2022-11-09 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-05 | 2022-11-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-05 | 2022-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-05 | 2022-11-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-05 | 2022-11-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-05 | 2022-11-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-10-05 | 2022-11-09 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-10-05 | 2022-11-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-19 | 2022-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-24 | 2021-07-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-24 | 2021-07-30 | 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 | 2021-06-24 | 2021-07-30 | 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 | 2021-06-24 | 2021-07-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-07 | 2021-07-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-07 | 2021-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-09-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-30 | 2019-09-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-08 | 2019-09-04 | 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 | 2019-08-08 | 2019-09-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-08 | 2019-09-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-08 | 2019-09-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-08 | 2019-09-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-08 | 2019-09-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-08-08 | 2019-09-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-08 | 2019-09-04 | 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 | 2019-08-08 | 2019-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-08 | 2019-09-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-08 | 2019-09-04 | 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 | 2019-08-30 | 2019-08-30 | N |
