A list of the most recent deficiencies for The Laurels of Willow Creek. 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? |
|---|---|---|---|---|
| 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 | 2023-10-12 | 2023-11-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-10-12 | 2023-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-12 | 2023-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-12 | 2023-11-08 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-10-12 | 2023-11-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-13 | 2023-10-16 | 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 | 2023-09-13 | 2023-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-13 | 2023-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-13 | 2023-10-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-13 | 2023-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-13 | 2023-10-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-13 | 2023-10-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-13 | 2023-10-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-09-13 | 2023-10-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-13 | 2023-10-16 | N |
| Post nurse staffing information every day. | Health | 2023-09-13 | 2023-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-13 | 2023-10-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-13 | 2023-10-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-13 | 2023-10-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-13 | 2023-10-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-13 | 2023-10-16 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-13 | 2023-10-16 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-13 | 2023-10-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-24 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-06-02 | Y |
| Have proper power supply for life support equipment. | Fire Safety | 2022-03-30 | 2022-05-10 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-30 | 2022-05-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-24 | 2022-04-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-24 | 2022-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-24 | 2022-04-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-24 | 2022-04-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 2022-04-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-24 | 2022-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-24 | 2022-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-24 | 2022-04-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-24 | 2022-04-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-24 | 2022-04-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-24 | 2022-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-24 | 2022-04-19 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-03-24 | 2022-04-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-21 | 2019-05-22 | 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 | 2019-03-21 | 2019-05-22 | 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 | 2019-03-21 | 2019-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-14 | 2019-04-26 | N |
| 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 | 2019-03-14 | 2019-04-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-14 | 2019-04-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-14 | 2019-04-26 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-14 | 2019-04-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-03-14 | 2019-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-14 | 2019-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-14 | 2019-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-14 | 2019-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-14 | 2019-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-14 | 2019-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-14 | 2019-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-14 | 2019-04-26 | N |
| 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 | 2019-03-14 | 2019-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-14 | 2019-04-26 | N |
| 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 | 2019-03-14 | 2019-04-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-03-14 | 2019-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-14 | 2019-04-26 | N |
