Deficiency Records for Willow Crossing Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Crossing Health and Rehabilitation Center. 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 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 | 2023-10-26 | 2023-11-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-11-13 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-10-26 | 2023-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-06 | 2023-10-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Meet other general requirements. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-20 | 2023-04-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-09 | 2023-03-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-09 | 2023-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-09 | 2023-03-24 | 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 | 2023-03-09 | 2023-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-09 | 2023-03-24 | 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 | 2023-03-09 | 2023-03-24 | 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 | 2023-03-09 | 2023-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-03-24 | 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 | 2022-09-16 | 2022-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-16 | 2022-10-13 | Y |
| Meet other general requirements. | Fire Safety | 2022-04-12 | 2022-04-30 | 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 | 2022-04-12 | 2022-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Have an externally vented heating system. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-12 | 2022-04-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-01 | 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 | 2022-03-17 | 2022-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-17 | 2022-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-17 | 2022-04-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-16 | 2021-03-30 | 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 | 2020-08-06 | 2020-08-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2020-08-06 | 2020-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-06 | 2020-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-06 | 2020-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-06 | 2020-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-06 | 2020-03-31 | 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 | 2020-03-06 | 2020-03-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-06 | 2020-03-31 | N |
