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Deficiency Records for Willow Creek Post Acute
View the most recent health deficiencies and inspection results for Willow Creek Post Acute. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Willow Creek Post Acute. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2026-02-12 | 2026-04-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2026-02-12 | 2026-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-10-09 | 2024-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-09 | 2024-11-01 | 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 | 2024-10-09 | 2024-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-11 | 2024-08-02 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-08-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-08-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-30 | 2023-08-10 | Y |
| Post nurse staffing information every day. | Health | 2023-06-30 | 2023-08-10 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-30 | 2023-08-10 | Y |
| 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 | 2023-06-30 | 2023-08-10 | Y |
| 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 | 2023-06-30 | 2023-08-10 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-30 | 2023-08-10 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2023-06-30 | 2023-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-30 | 2023-08-10 | Y |
| 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 | 2023-06-30 | 2023-08-10 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-30 | 2023-08-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-30 | 2023-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-30 | 2023-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-30 | 2023-08-10 | 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 | 2023-06-30 | 2023-08-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-30 | 2023-08-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-30 | 2023-07-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-30 | 2022-09-27 | Y |