Deficiency Records for Willows Health Center
Updated as of January 01, 2023
This is not the most recent data for Willows Health Center. For the most recent information, click here.
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? |
---|---|---|---|---|
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 |
Perform COVID19 testing on residents and staff. | Health | 2020-11-24 | 2021-01-05 | 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 | 2019-09-19 | 2019-10-13 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-19 | 2019-10-13 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-19 | 2019-10-13 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-19 | 2019-10-13 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-19 | 2019-10-13 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-10-04 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-12 | 2019-10-04 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-04 | N |