A list of the most recent deficiencies for Willows Health 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-06 | 2023-10-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-06 | 2023-10-26 | 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 | 2023-10-06 | 2023-10-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-06 | 2023-10-26 | 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 | 2023-10-06 | 2023-10-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-06 | 2023-10-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-21 | 2023-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-21 | 2023-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-22 | 2023-03-17 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-22 | 2023-03-17 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-01 | 2022-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-17 | 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 | 2022-07-20 | 2022-08-17 | 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 | 2022-07-20 | 2022-08-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-20 | 2022-08-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-20 | 2022-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-17 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-10-05 | 2021-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-08-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-14 | 2021-08-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Develop a communication plan. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Establish methods for sharing information. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-21 | 2021-06-14 | 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 | 2021-04-21 | 2021-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-21 | 2021-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-15 | 2021-05-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-15 | 2021-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-05-14 | N |
