Deficiency Records for Sharon Health Care Willows
Updated as of February 01, 2022
This is not the most recent data for Sharon Health Care Willows. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Report COVID19 data to residents and families. | Health | 2021-01-06 | 2021-02-05 | Y |
| Keep all essential equipment working safely. | Health | 2021-01-06 | 2021-02-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-01-06 | 2021-02-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-01-06 | 2021-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-06 | 2021-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-06 | 2021-02-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-01-06 | 2021-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-15 | 2020-12-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-11-13 | 2020-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-10-14 | 2020-10-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-08-12 | 2020-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-29 | 2020-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-26 | 2020-03-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-17 | 2020-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-19 | 2019-10-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-01 | 2019-08-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-01 | 2019-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-17 | 2019-08-07 | 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 | 2019-07-17 | 2019-08-07 | 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 | 2019-07-17 | 2019-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-07-17 | 2019-08-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-17 | 2019-07-30 | 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 | 2019-03-26 | 2019-04-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-26 | 2019-04-30 | 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 | 2019-03-26 | 2019-04-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-17 | 2019-04-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-06 | 2019-02-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-06 | 2019-02-26 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-22 | 2018-09-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-22 | 2018-09-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-22 | 2018-09-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-22 | 2018-09-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-17 | 2018-09-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-17 | 2018-09-03 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-08-17 | 2018-09-03 | 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 | 2018-08-17 | 2018-09-03 | N |
| Post nurse staffing information every day. | Health | 2018-08-17 | 2018-09-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-17 | 2018-09-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-17 | 2018-09-03 | N |
