Deficiency Records for Willow Knoll Post-Acute and Senior Living
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Knoll Post-Acute and Senior Living. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-09 | 2021-11-23 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-09 | 2021-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-09 | 2021-08-25 | 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 | 2021-07-09 | 2021-08-25 | 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 | 2021-07-09 | 2021-08-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-09 | 2021-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-09 | 2021-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-24 | 2021-08-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-24 | 2021-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-24 | 2021-08-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Develop a communication plan. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-28 | 2021-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-16 | 2021-08-25 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-16 | 2021-08-25 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-16 | 2021-06-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-08 | 2021-05-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-08 | 2021-05-03 | 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 | 2021-04-08 | 2021-05-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-04-08 | 2021-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-14 | 2019-05-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-14 | 2019-05-31 | 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 | 2019-03-14 | 2019-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-14 | 2019-05-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-03-14 | 2019-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-14 | 2019-05-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-14 | 2019-05-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-14 | 2019-05-31 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-01-29 | 2018-02-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-01-29 | 2018-02-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-01-29 | 2018-02-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-01-29 | 2018-02-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-01-29 | 2018-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-29 | 2018-02-28 | 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 | 2018-01-29 | 2018-02-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-01-29 | 2018-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-29 | 2018-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-01-29 | 2018-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-29 | 2018-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-29 | 2018-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-29 | 2018-02-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-01-29 | 2018-02-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-01-29 | 2018-02-28 | N |
| Post nurse staffing information every day. | Health | 2018-01-29 | 2018-02-28 | 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 | 2018-01-29 | 2018-02-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-29 | 2018-02-28 | 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 | 2018-01-29 | 2018-02-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-01-29 | 2018-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-29 | 2018-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-29 | 2018-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-29 | 2018-02-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-01-29 | 2018-02-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-18 | 2018-02-28 | 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 | 2018-01-18 | 2018-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-18 | 2018-02-28 | N |
