A list of the most recent deficiencies for Life Care Center of The 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? |
|---|---|---|---|---|
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-23 | 2024-02-14 | 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 | 2024-01-23 | 2024-02-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-23 | 2024-02-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-03 | 2024-02-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-03 | 2024-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-03 | 2024-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-03 | 2024-02-01 | 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 | 2024-01-03 | 2024-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-03 | 2024-02-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-03 | 2024-02-01 | 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 | 2024-01-03 | 2024-02-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-01-03 | 2024-02-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-03 | 2024-02-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-03 | 2024-02-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-03 | 2024-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-02-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-18 | 2023-05-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-21 | 2023-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-21 | 2023-05-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-21 | 2023-05-11 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-21 | 2023-05-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-03 | 2023-01-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-03 | 2023-01-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-03 | 2023-01-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-03 | 2023-01-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-01-03 | 2023-01-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-03 | 2023-01-26 | 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 | 2023-01-03 | 2023-01-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-03 | 2023-01-26 | 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 | 2023-01-03 | 2023-01-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-03 | 2023-01-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-03 | 2023-01-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-03 | 2023-01-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-03 | 2023-01-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-03 | 2023-01-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-10 | 2023-01-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-01-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-10 | 2023-01-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-10 | 2023-01-26 | 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 | 2022-06-02 | 2022-06-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-02 | 2022-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-02 | 2022-06-23 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-04 | 2022-04-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-04 | 2021-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-28 | 2021-11-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-19 | 2021-11-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-19 | 2021-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-19 | 2021-11-16 | 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 | 2021-10-19 | 2021-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-19 | 2021-11-16 | 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 | 2021-10-19 | 2021-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-19 | 2021-11-16 | N |
| Post nurse staffing information every day. | Health | 2021-10-19 | 2021-11-16 | 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 | 2021-10-19 | 2021-11-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-19 | 2021-11-16 | 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 | 2021-10-19 | 2021-11-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-19 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-16 | N |
