Deficiency Records for Willow Springs Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Willow Springs Health and Rehabilitation 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-10 | 2024-02-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-10 | 2024-02-07 | 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 | 2024-01-10 | 2024-02-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-10 | 2024-02-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-10 | 2024-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-10-12 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-11-30 | 2023-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-30 | 2023-01-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-10 | 2022-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-13 | 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 | 2022-11-10 | 2022-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-13 | 2022-05-06 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-09-17 | 2021-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-17 | 2021-10-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-09-17 | 2021-10-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-09-17 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-08 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-09-16 | 2021-10-01 | 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 | 2021-09-16 | 2021-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-10 | 2021-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-10-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-26 | 2019-10-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-26 | 2019-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-26 | 2019-09-27 | N |
