A list of the most recent deficiencies for Willow Manor. 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 methods for sharing information. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-06 | 2024-02-29 | 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 | 2024-02-06 | 2024-02-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-06 | 2024-02-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-02-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-26 | 2024-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-26 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-01-26 | 2024-02-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-23 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-26 | 2024-02-23 | N |
| Have policies on smoking. | Health | 2024-01-26 | 2024-02-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-11 | 2023-06-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-11 | 2023-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-04 | 2022-11-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-04 | 2022-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-12 | 2022-05-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-12 | 2022-05-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-12 | 2022-05-03 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-05 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-13 | 2022-01-05 | Y |
| Post nurse staffing information every day. | Health | 2021-06-28 | 2021-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-28 | 2021-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-07 | 2021-09-27 | Y |
| Post nurse staffing information every day. | Health | 2021-09-07 | 2021-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-09-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-28 | 2021-08-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-28 | 2021-08-31 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-06-28 | 2021-08-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-28 | 2021-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-28 | 2021-08-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-28 | 2021-08-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-28 | 2021-08-06 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-28 | 2021-08-06 | 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 | 2021-06-28 | 2021-08-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-28 | 2021-08-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-28 | 2021-08-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-28 | 2021-08-06 | 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 | 2021-06-28 | 2021-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-28 | 2021-08-06 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-28 | 2021-08-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-28 | 2021-08-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-08 | 2021-08-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-08 | 2021-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-08 | 2021-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-08 | 2021-08-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-07-08 | 2021-08-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Develop a communication plan. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Establish methods for sharing information. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-24 | 2020-03-25 | 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 | 2019-12-20 | 2020-03-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-20 | 2020-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-20 | 2020-02-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-20 | 2020-02-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-20 | 2020-02-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-20 | 2020-02-06 | N |
| 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 | 2019-12-20 | 2020-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-20 | 2020-02-06 | 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 | 2019-12-20 | 2020-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-20 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-20 | 2020-02-06 | 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 | 2019-12-20 | 2020-02-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-20 | 2020-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-20 | 2020-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-20 | 2020-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-20 | 2020-02-06 | N |
