A list of the most recent deficiencies for Willow Creek Retirement 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-11 | 2023-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-09-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-23 | 2023-03-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-23 | 2023-03-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-23 | 2023-03-29 | 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 | 2023-02-23 | 2023-03-29 | 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 | 2023-02-23 | 2023-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-23 | 2023-03-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-24 | 2023-03-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-27 | 2022-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-24 | 2022-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-14 | 2021-07-20 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-03 | 2019-11-01 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-10-03 | 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 | 2019-10-03 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-03 | 2019-11-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-16 | 2017-12-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-11-21 | 2017-12-11 | N |
