Deficiency Records for Willow Springs Care and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Willow Springs Care and Rehabilitation. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-22 | 2023-08-18 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-07-22 | 2023-08-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-22 | 2023-08-18 | 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 | 2023-07-22 | 2023-08-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-22 | 2023-08-18 | 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 | 2023-07-22 | 2023-08-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-22 | 2023-08-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-22 | 2023-08-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-22 | 2023-08-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-22 | 2023-08-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-22 | 2023-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-22 | 2023-08-18 | 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 | 2023-07-22 | 2023-08-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-22 | 2023-08-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-22 | 2023-08-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-22 | 2023-08-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-22 | 2023-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-22 | 2023-08-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-22 | 2023-08-18 | N |
| 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 | 2023-07-22 | 2023-08-18 | 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 | 2023-07-22 | 2023-08-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-22 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-22 | 2023-08-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-18 | 2023-08-15 | N |
| Meet other general requirements. | Fire Safety | 2023-07-18 | 2023-08-07 | 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 | 2023-07-18 | 2023-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-18 | 2023-08-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-25 | 2022-08-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-16 | 2022-07-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-06-28 | 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 | 2022-05-12 | 2022-06-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-12 | 2022-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-06-17 | 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 | 2022-05-12 | 2022-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-12 | 2022-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-12 | 2022-06-17 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-12 | 2022-06-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-10 | 2022-06-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-10 | 2022-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-10 | 2022-06-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-10 | 2022-06-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-10 | 2022-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-22 | 2021-08-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-27 | 2021-06-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-25 | 2019-05-18 | 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 | 2019-03-25 | 2019-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-25 | 2019-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-25 | 2019-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-25 | 2019-05-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-25 | 2019-05-18 | N |
| 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 | 2019-03-25 | 2019-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-25 | 2019-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-25 | 2019-05-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-15 | 2019-04-15 | N |
