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Deficiency Records for The Willows at Ramapo Rehab and Nursing Center

View the most recent health deficiencies and inspection results for The Willows at Ramapo Rehab and Nursing Center. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for The Willows at Ramapo Rehab and Nursing Center. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Have exits that are accessible at all times. Fire Safety 2026-03-13 2026-04-24 N
Install proper backup exit lighting. Fire Safety 2026-03-13 2026-04-24 N
Provide properly protected cooking facilities. Fire Safety 2026-03-13 2026-04-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2026-03-13 2026-04-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2026-03-13 2026-04-24 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2026-03-13 2026-04-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2026-03-13 2026-04-24 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2026-03-13 2026-04-24 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2026-03-13 2026-04-22 N
Honor the resident's right to manage his or her financial affairs. Health 2026-03-13 2026-04-22 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 2026-03-13 2026-04-22 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2026-03-13 2026-04-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2026-03-13 2026-04-22 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2026-03-13 2026-04-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2026-03-13 2026-04-22 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-10-24 2025-12-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-10-24 2025-12-18 Y
Provide and implement an infection prevention and control program. Health 2025-07-24 2025-11-04 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 2025-03-04 2025-04-08 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-11-17 2023-12-30 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 2023-11-17 2023-12-30 N
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
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-17 2023-12-30 Y
Respond appropriately to all alleged violations. Health 2023-11-17 2023-12-30 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-17 2023-12-30 N
Provide activities to meet all resident's needs. Health 2023-11-17 2023-12-30 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-11-17 2023-12-28 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 2023-11-17 2023-12-28 N
Have exits that are accessible at all times. Fire Safety 2023-11-17 2023-12-28 N
Install proper backup exit lighting. Fire Safety 2023-11-17 2023-12-28 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-11-17 2023-12-28 N
Provide properly protected cooking facilities. Fire Safety 2023-11-17 2023-12-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-17 2023-12-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-11-17 2023-12-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-17 2023-12-28 N
Have proper medical gas storage and administration areas. Fire Safety 2023-11-17 2023-12-28 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
Provide and implement an infection prevention and control program. 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
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
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
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2019-04-18 2019-06-14 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-04-18 2019-05-31 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-04-18 2019-05-31 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-04-18 2019-05-31 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2019-04-18 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 2019-04-18 2019-05-31 N
Establish roles under a Waiver declared by secretary. Fire Safety 2019-04-18 2019-05-31 N
Address subsistence needs for staff and patients. Fire Safety 2019-04-18 2019-05-31 N

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