A list of the most recent deficiencies for Willows Health and Rehab Ctr. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-03 | 2022-06-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-05-09 | 2022-06-02 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-05-09 | 2022-06-02 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-05-09 | 2022-06-02 | 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 | 2022-05-09 | 2022-06-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-05-09 | 2022-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-09 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-09 | 2022-06-02 | 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 | 2022-05-09 | 2022-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-09 | 2022-06-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-09 | 2022-06-02 | 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 | 2022-05-09 | 2022-06-02 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-09 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-09 | 2022-06-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-09 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-09 | 2022-06-02 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-03 | 2022-06-02 | 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 | 2022-05-03 | 2022-06-02 | 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 | 2022-05-03 | 2022-06-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-03 | 2022-06-02 | 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 | 2022-05-03 | 2022-06-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-05-03 | 2022-06-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-30 | 2022-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-20 | 2022-02-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-20 | 2022-02-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-20 | 2022-02-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-01 | 2021-11-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-01 | 2021-11-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-01 | 2021-11-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-01 | 2021-11-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-01 | 2021-11-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-04 | 2019-05-03 | 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 | 2019-04-04 | 2019-05-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-04 | 2019-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-04 | 2019-05-03 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-04 | 2019-05-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-04 | 2019-05-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-03 | 2019-05-03 | 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 | 2019-04-03 | 2019-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-03 | 2019-05-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-16 | 2018-05-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-16 | 2018-05-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-16 | 2018-05-04 | N |
| Provide activities to meet all resident's needs. | Health | 2018-03-16 | 2018-05-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-16 | 2018-05-04 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-03-16 | 2018-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-16 | 2018-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-16 | 2018-05-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-16 | 2018-05-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-13 | 2018-05-04 | N |
| Dispose of garbage and refuse properly. | Health | 2018-03-16 | 2018-04-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-03-13 | 2018-04-06 | N |
