Deficiency Records for Willow Terrace
Updated as of January 01, 2019
This is not the most recent data for Willow Terrace. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-17 | 2018-08-01 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-07-17 | 2018-08-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-02 | 2018-07-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-04-24 | 2018-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-24 | 2018-07-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-24 | 2018-06-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-24 | 2018-06-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-24 | 2018-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-02 | 2018-06-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-05-02 | 2018-06-11 | N |
| 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 | 2018-05-02 | 2018-06-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-02 | 2018-06-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-05-02 | 2018-06-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-05-02 | 2018-06-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-05-02 | 2018-06-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-02 | 2018-06-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-05-02 | 2018-06-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-02 | 2018-06-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-02 | 2018-06-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-02 | 2018-06-11 | 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 | 2018-05-02 | 2018-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-02 | 2018-06-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-02 | 2018-06-11 | 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 | 2018-05-02 | 2018-06-11 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-05-02 | 2018-06-11 | 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 | 2018-05-02 | 2018-06-11 | N |
| Dispose of garbage and refuse properly. | Health | 2018-05-02 | 2018-06-11 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2018-05-02 | 2018-06-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-02 | 2018-06-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-05-02 | 2018-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-02 | 2018-06-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-02 | 2018-06-11 | 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 | 2018-05-02 | 2018-06-11 | Y |
| Post nurse staffing information every day. | Health | 2018-05-02 | 2018-06-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-05-02 | 2018-06-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-05-02 | 2018-06-11 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-05-02 | 2018-06-11 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-05-02 | 2018-06-11 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-05-02 | 2018-06-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-22 | 2018-04-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-22 | 2018-04-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-01-19 | 2018-02-08 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-11 | 2017-09-30 | Y |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-08-11 | 2017-09-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-11 | 2017-09-30 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-22 | 2017-08-10 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-03-01 | 2017-04-30 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-01 | 2017-04-30 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-01 | 2017-04-30 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-01 | 2017-04-30 | N |
| Meet other general requirements. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-03-06 | 2017-04-23 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-05 | 2017-02-03 | Y |
| Maintain comfortable and safe temperature levels. | Health | 2016-07-24 | 2016-09-22 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-07-24 | 2016-09-22 | Y |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-02-22 | 2016-05-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-02-19 | 2016-04-05 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-02-19 | 2016-04-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-02-19 | 2016-04-05 | Y |
| A two-hour-resistant firewall separation. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Exit stairways and towers that are smoke proof. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Portable fire extinguishers. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-02-22 | 2016-03-31 | N |
