Deficiency Records for Willow Creek Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Creek Nursing 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? |
|---|---|---|---|---|
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-30 | 2023-12-28 | 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 | 2023-11-30 | 2023-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-30 | 2023-12-28 | 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 | 2023-11-30 | 2023-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2023-12-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-28 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-18 | 2022-12-22 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-11-18 | 2022-12-22 | 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 | 2022-11-18 | 2022-12-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-18 | 2022-12-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-18 | 2022-12-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-18 | 2022-12-22 | 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 | 2022-11-18 | 2022-12-22 | 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 | 2022-11-18 | 2022-12-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-18 | 2022-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-17 | 2021-09-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-29 | 2021-09-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-29 | 2021-09-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-29 | 2021-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-09-07 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-29 | 2021-09-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-29 | 2021-09-07 | Y |
