Deficiency Records for Willow Knoll Post-Acute and Senior Living
Updated as of March 01, 2020
This is not the most recent data for Willow Knoll Post-Acute and Senior Living. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-11-27 | 2020-01-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-27 | 2020-01-10 | Y |
| Keep all essential equipment working safely. | Health | 2019-11-27 | 2020-01-10 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-26 | 2019-11-26 | Y |
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-07 | 2019-05-31 | Y |
| 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 | 2019-05-07 | 2019-05-31 | 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-06 | 2018-09-25 | Y |
| 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 |
| 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 | 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 and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2017-11-29 | 2017-12-29 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2017-11-29 | 2017-12-29 | Y |
| Provide housekeeping and maintenance services. | Health | 2017-11-01 | 2017-12-29 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-01 | 2017-12-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-06-27 | 2017-07-21 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-04-26 | 2017-06-09 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Restrictions on the use of highly flammable decorations. | Fire Safety | 2016-10-13 | 2016-11-14 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-10-13 | 2016-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-10-13 | 2016-11-14 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2016-10-13 | 2016-11-14 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-10-13 | 2016-11-14 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-10-13 | 2016-11-14 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-10-13 | 2016-11-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-10-13 | 2016-11-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-10-13 | 2016-11-14 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-10-13 | 2016-11-14 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-10-13 | 2016-11-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-10-13 | 2016-11-14 | N |
