Deficiency Records for Willow Terrace

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Updated as of March 01, 2024

A list of the most recent deficiencies for Willow Terrace. 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?
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-09-28 2023-11-01 Y
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2023-06-20 2023-07-26 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-06-20 2023-07-26 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-06-20 2023-07-26 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-06-20 2023-07-26 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-06-20 2023-07-26 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-06-20 2023-07-26 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2023-06-02 2023-07-18 N
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 2023-06-02 2023-07-18 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-06-02 2023-07-18 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-06-02 2023-07-18 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 2023-06-02 2023-07-18 N
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Health 2023-06-02 2023-07-18 N
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 2023-06-02 2023-07-18 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2023-06-02 2023-07-18 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-06-02 2023-07-18 N
Provide activities to meet all resident's needs. Health 2023-06-02 2023-07-18 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 2023-06-02 2023-07-18 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2023-06-02 2023-07-18 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 2023-03-28 2023-04-28 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-12-06 2023-01-09 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-07-21 2022-08-03 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-06-30 2022-07-29 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-06-30 2022-07-29 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-06-30 2022-07-29 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2022-06-24 2022-07-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-24 2022-07-22 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-06-24 2022-07-22 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-06-24 2022-07-22 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2022-05-31 2022-06-14 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-05-31 2022-06-14 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-31 2022-06-14 Y
Provide routine and 24-hour emergency dental care for each resident. Health 2021-10-07 2021-11-11 Y
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2021-04-28 2021-06-16 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-28 2021-06-16 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2021-04-28 2021-06-16 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2021-04-28 2021-06-16 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 2021-04-28 2021-06-16 N
Provide and implement an infection prevention and control program. Health 2021-04-28 2021-06-16 N
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2021-03-19 2021-05-17 N
Install an approved automatic sprinkler system. Fire Safety 2021-03-19 2021-05-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-03-19 2021-05-17 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-03-19 2021-05-17 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-03-19 2021-05-17 N
Have proper medical gas storage and administration areas. Fire Safety 2021-03-19 2021-05-17 N