A list of the most recent deficiencies for Sharon Health Care Willows. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-19 | 2024-01-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-05 | 2023-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-15 | 2023-09-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-31 | 2023-09-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-31 | 2023-09-22 | N |
| Provide activities to meet all resident's needs. | Health | 2023-08-31 | 2023-09-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-31 | 2023-09-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-31 | 2023-09-22 | 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 | 2023-08-31 | 2023-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-09-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-30 | 2023-09-22 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-08-31 | 2023-09-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-31 | 2023-09-21 | 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 | 2023-08-31 | 2023-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-09-21 | 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 | 2023-08-31 | 2023-09-20 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-08-30 | 2023-09-19 | 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 | 2023-08-30 | 2023-09-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-30 | 2023-09-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-30 | 2023-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-12 | 2023-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-26 | 2023-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-12 | 2023-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2022-12-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-11 | Y |
| 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 | 2022-10-21 | 2022-11-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-07-27 | 2022-08-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-27 | 2022-08-12 | 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 | 2022-07-27 | 2022-08-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-27 | 2022-08-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-27 | 2022-08-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-27 | 2022-08-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-07-20 | 2022-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-07-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-07-22 | 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 | 2022-07-20 | 2022-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-20 | 2022-07-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-20 | 2022-07-21 | 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 | 2022-07-20 | 2022-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-26 | 2022-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-14 | 2021-12-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-11 | 2021-09-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-11 | 2021-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-11 | 2021-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-07-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-29 | 2021-06-21 | 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 | 2021-04-29 | 2021-05-24 | 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 | 2021-04-29 | 2021-05-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-29 | 2021-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-29 | 2021-05-21 | 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 | 2021-04-29 | 2021-05-21 | 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 | 2021-04-29 | 2021-05-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-29 | 2021-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-05-21 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-28 | 2021-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-05-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-04-29 | 2021-05-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-28 | 2021-05-19 | 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 | 2021-04-28 | 2021-05-19 | 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 | 2021-04-29 | 2021-05-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-29 | 2021-05-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Develop a communication plan. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Establish methods for sharing information. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2021-04-28 | 2021-05-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-28 | 2021-05-04 | N |
