A list of the most recent deficiencies for Willow Rehab and Nursing. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-11-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-16 | 2023-11-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-16 | 2023-11-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-07 | 2023-07-21 | Y |
| 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 | 2023-01-26 | 2023-02-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-02-28 | 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 | 2023-01-26 | 2023-02-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-26 | 2023-02-28 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-10-21 | 2022-11-18 | 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 | 2022-10-21 | 2022-11-18 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-21 | 2022-11-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-11-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-21 | 2022-11-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-18 | Y |
| 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 | 2022-10-21 | 2022-11-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-21 | 2022-11-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-21 | 2022-11-18 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-21 | 2022-11-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-21 | 2022-11-18 | Y |
| 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 | 2022-10-21 | 2022-11-18 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-21 | 2022-11-18 | Y |
| 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 | 2022-10-21 | 2022-11-18 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-21 | 2022-11-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-21 | 2022-11-18 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-10-21 | 2022-11-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-21 | 2022-11-18 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-10-18 | 2022-10-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-30 | 2022-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-30 | 2022-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-30 | 2022-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-09-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-30 | 2022-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-06 | 2021-09-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-06 | 2021-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-06 | 2021-09-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-06 | 2021-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-06 | 2021-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-20 | 2019-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-20 | 2019-10-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-21 | 2019-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-21 | 2019-10-01 | 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 | 2019-08-21 | 2019-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-21 | 2019-10-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-08-21 | 2019-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-21 | 2019-10-01 | N |
