A list of the most recent deficiencies for Willows of New Castle. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-15 | 2024-03-23 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-02-15 | 2024-03-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-15 | 2024-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-15 | 2024-03-15 | N |
| Meet other general requirements. | Fire Safety | 2024-02-15 | 2024-03-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-15 | 2024-03-01 | 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 | 2024-02-15 | 2024-02-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-29 | 2024-02-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-29 | 2024-02-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-29 | 2024-02-09 | 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 | 2024-01-29 | 2024-02-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-29 | 2024-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-29 | 2024-02-09 | 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 | 2024-01-29 | 2024-02-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-29 | 2024-02-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-29 | 2024-02-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-01-29 | 2024-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-29 | 2024-02-09 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-01 | 2023-01-02 | 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 | 2022-12-01 | 2023-01-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-01 | 2023-01-02 | 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 | 2022-12-01 | 2023-01-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-12-01 | 2023-01-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-03 | 2022-11-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-03 | 2022-11-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-03 | 2022-11-21 | 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 | 2019-12-04 | 2020-01-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-11 | 2019-11-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-11 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-11 | 2019-11-01 | 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 | 2019-10-11 | 2019-11-01 | N |
