A list of the most recent deficiencies for Willows Center. 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? |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-27 | 2023-11-03 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-31 | 2023-10-13 | 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 | 2023-08-31 | 2023-10-13 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-13 | Y |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-07 | 2022-08-02 | N |
Ensure each resident receives an accurate assessment. | Health | 2022-06-08 | 2022-07-15 | 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 | 2022-06-08 | 2022-07-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-07-15 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-08 | 2022-07-15 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-08 | 2022-07-15 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2022-06-08 | 2022-07-15 | 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 | 2022-06-08 | 2022-07-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-08 | 2022-07-15 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-08 | 2022-07-15 | 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 | 2022-06-07 | 2022-07-12 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-07 | 2022-07-12 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-07 | 2022-07-12 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-07 | 2022-07-12 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-10 | 2022-02-04 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-05 | 2021-04-21 | 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 | 2021-03-05 | 2021-04-21 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-05 | 2021-04-21 | 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 | 2021-03-03 | 2021-04-15 | 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 | 2021-03-03 | 2021-04-15 | 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 | 2019-10-30 | 2019-12-11 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-30 | 2019-12-11 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2019-10-30 | 2019-12-11 | 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 | 2019-10-30 | 2019-12-11 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-29 | 2019-12-11 | 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 | 2019-10-29 | 2019-12-11 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-10-29 | 2019-12-11 | N |