A list of the most recent deficiencies for Willows at Bellevue. 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 | 2023-06-01 | 2023-06-08 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-02 | 2023-03-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-02 | 2023-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-02-02 | 2023-03-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-02 | 2023-03-03 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-31 | 2023-03-03 | 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 | 2023-01-31 | 2023-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-31 | 2023-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-31 | 2023-03-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-31 | 2023-03-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-10 | 2022-02-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-28 | 2020-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-28 | 2020-01-31 | 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 | 2019-12-28 | 2020-01-31 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-26 | 2020-01-31 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-12-26 | 2020-01-31 | 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 | 2019-12-26 | 2020-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-26 | 2020-01-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-26 | 2020-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-26 | 2020-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-26 | 2020-01-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-01 | 2018-12-07 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-11-01 | 2018-12-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-01 | 2018-12-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-10-31 | 2018-12-07 | 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 | 2018-10-31 | 2018-12-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-31 | 2018-12-07 | N |
