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 |