A list of the most recent deficiencies for Willow Rose Rehab and Health. 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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-28 | 2023-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-11 | 2023-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-18 | 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 | 2023-09-28 | 2023-10-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-28 | 2023-10-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-28 | 2023-10-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-09-28 | 2023-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-18 | 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 | 2023-09-28 | 2023-10-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-28 | 2023-10-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-06 | 2023-07-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-06 | 2023-07-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-06 | 2023-07-19 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-12-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-24 | 2022-11-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-24 | 2022-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-24 | 2022-11-17 | 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 | 2022-10-24 | 2022-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-24 | 2022-11-17 | 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 | 2022-10-24 | 2022-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-24 | 2022-11-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-24 | 2022-11-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-24 | 2022-11-17 | 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 | 2022-10-24 | 2022-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-24 | 2022-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-24 | 2022-11-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-24 | 2022-11-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-24 | 2022-11-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-24 | 2022-11-17 | 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 | 2022-02-09 | 2022-02-23 | 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 | 2022-02-09 | 2022-02-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-09 | 2022-02-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-09 | 2022-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-09 | 2022-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-09 | 2022-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-09 | 2022-02-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-21 | 2022-01-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-18 | 2021-12-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-02 | 2021-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-12-02 | 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 | 2021-11-18 | 2021-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-12-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-11-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-18 | 2021-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-11-30 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-18 | 2021-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2021-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-11-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-02 | 2021-11-17 | Y |
