Deficiency Records for The Willows at Ramapo Rehab and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Willows at Ramapo Rehab and Nursing 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-17 | 2023-12-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-17 | 2023-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-17 | 2023-12-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-30 | 2023-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-02-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-18 | 2023-02-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-11-30 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-04-18 | 2019-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-18 | 2019-06-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-18 | 2019-06-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-18 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-06-14 | 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 | 2019-04-18 | 2019-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-18 | 2019-06-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-18 | 2019-06-14 | 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 | 2019-04-18 | 2019-06-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-18 | 2019-06-14 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-18 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-16 | 2019-05-31 | 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 | 2019-04-16 | 2019-05-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-16 | 2019-05-31 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-07 | 2017-08-11 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-07 | 2017-08-11 | 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 | 2017-07-07 | 2017-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-07 | 2017-08-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-07-07 | 2017-08-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-07-07 | 2017-08-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-07 | 2017-08-11 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-10-31 | 2016-12-30 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-10-31 | 2016-12-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-10-31 | 2016-12-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-10-31 | 2016-12-30 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-31 | 2016-12-30 | N |
