A list of the most recent deficiencies for Embassy of Willard. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-06 | 2023-11-14 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-13 | 2022-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-23 | 2022-04-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-23 | 2022-04-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-16 | 2022-03-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-12 | 2021-12-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-12 | 2021-12-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-12 | 2021-12-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-12 | 2021-12-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-12 | 2021-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-12 | 2021-12-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-12 | 2021-12-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-07 | 2021-12-07 | 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 | 2021-11-07 | 2021-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-07 | 2021-12-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-22 | 2021-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-12 | 2021-04-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-24 | 2019-06-14 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-05-24 | 2019-06-14 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-05-24 | 2019-06-14 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-05-24 | 2019-06-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-05-24 | 2019-06-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-24 | 2019-06-14 | 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 | 2019-05-24 | 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 | 2019-05-24 | 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 | 2019-05-24 | 2019-06-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-24 | 2019-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-24 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-24 | 2019-06-14 | 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 | 2019-05-24 | 2019-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-24 | 2019-06-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-05-24 | 2019-06-14 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-05-24 | 2019-06-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-05-24 | 2019-06-14 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-05-24 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-24 | 2019-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-24 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Develop a communication plan. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-21 | 2019-06-14 | 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 | 2019-05-21 | 2019-06-14 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-21 | 2019-06-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-06-14 | 2018-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-14 | 2018-09-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-06-14 | 2018-09-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-06-14 | 2018-09-10 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-12 | 2018-09-10 | N |
