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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-08 | 2024-03-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-08 | 2024-03-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-08 | 2024-03-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-08 | 2024-03-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-08 | 2024-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-08 | 2024-03-14 | N |
| Post nurse staffing information every day. | Health | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | 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 | 2024-02-08 | 2024-03-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-08 | 2024-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | 2024-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-08 | 2024-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-03-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-08 | 2024-03-14 | N |
| Keep all essential equipment working safely. | Health | 2024-02-08 | 2024-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-06 | 2024-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-02-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-06 | 2024-02-22 | N |
| 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 |
