Deficiency Records for Willow Terrace
Updated as of January 01, 2021
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? |
|---|---|---|---|---|
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-09-10 | 2020-11-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-09-10 | 2020-10-30 | 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 | 2020-09-10 | 2020-10-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2020-09-10 | 2020-10-30 | 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 | 2020-09-10 | 2020-10-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-10 | 2020-10-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-08-28 | 2020-10-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-28 | 2020-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-08-28 | 2020-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-28 | 2020-10-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-08-28 | 2020-10-20 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2020-08-28 | 2020-10-20 | N |
| Dispose of garbage and refuse properly. | Health | 2020-08-28 | 2020-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-28 | 2020-10-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-08-28 | 2020-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-05 | 2019-12-03 | 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 | 2019-09-20 | 2019-11-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-20 | 2019-11-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-20 | 2019-11-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-20 | 2019-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-12 | 2019-08-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Develop a communication plan. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Be properly staffed | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-24 | 2019-08-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-19 | 2019-08-02 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-06-19 | 2019-08-02 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-06-19 | 2019-08-02 | 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 | 2019-06-19 | 2019-08-02 | 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 | 2019-06-19 | 2019-08-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-19 | 2019-08-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-19 | 2019-08-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-19 | 2019-08-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-19 | 2019-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-19 | 2019-08-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide or obtain dental services for each resident. | Health | 2019-06-19 | 2019-08-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-19 | 2019-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-19 | 2019-08-02 | N |
| 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 | 2019-06-19 | 2019-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-19 | 2019-08-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-19 | 2019-08-02 | N |
| Have policies on smoking. | Health | 2019-06-19 | 2019-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-19 | 2019-08-02 | 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 | 2019-06-19 | 2019-08-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-23 | 2019-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-23 | 2019-06-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-31 | 2019-02-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-31 | 2019-02-11 | Y |
| 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 | 2019-01-10 | 2019-01-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-01-10 | 2019-01-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-10 | 2019-01-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-31 | 2018-12-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-31 | 2018-12-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2018-10-31 | 2018-12-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-31 | 2018-12-05 | Y |
| 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 | 2018-10-31 | 2018-12-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-31 | 2018-12-05 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-31 | 2018-12-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-31 | 2018-12-05 | 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 | 2018-10-31 | 2018-12-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-31 | 2018-12-05 | Y |
| 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 |
