Deficiency Records for Willow Springs Rehabilitation and Healthcare Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Springs Rehabilitation and Healthcare Ctr. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-03 | 2023-11-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-20 | 2023-01-19 | 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 | 2022-12-20 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-20 | 2023-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-01-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-20 | 2023-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-22 | 2022-07-18 | Y |
| 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 | 2022-06-22 | 2022-07-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-11-18 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-06-18 | 2021-07-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-18 | 2021-07-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-10-07 | 2020-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-07 | 2020-10-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-10-07 | 2020-10-30 | 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 | 2020-10-07 | 2020-10-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-12 | 2019-04-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-04-12 | 2019-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-12 | 2019-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-12 | 2019-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-12 | 2019-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-12 | 2019-04-15 | N |
