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Deficiency Records for Willowcreek Wellness and Rehabilitation
A list of the most recent deficiencies for Willowcreek Wellness and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Willowcreek Wellness 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-14 | 2024-09-25 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-08-14 | 2024-09-25 | 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 | 2024-08-14 | 2024-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-14 | 2024-09-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-14 | 2024-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-14 | 2024-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-14 | 2024-09-25 | 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 | 2024-08-14 | 2024-09-25 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-08-14 | 2024-09-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-08-14 | 2024-09-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-14 | 2024-09-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-08-14 | 2024-09-25 | N |
| 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 | 2024-08-14 | 2024-09-25 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-08-14 | 2024-09-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-14 | 2024-09-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-14 | 2024-09-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-24 | 2023-08-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-24 | 2023-08-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-08 | 2023-04-08 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-02 | 2023-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-02-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-03 | 2023-02-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-02 | 2022-05-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-02 | 2022-05-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-02 | 2022-05-23 | 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 | 2022-02-02 | 2022-04-01 | Y |
| 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 | 2022-02-02 | 2022-04-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-02-02 | 2022-03-14 | N |
| Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | Health | 2022-02-02 | 2022-03-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-02 | 2022-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-02 | 2022-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-02 | 2022-03-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-02 | 2022-03-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-02 | 2022-03-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-02 | 2022-03-14 | 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 | 2022-02-02 | 2022-03-14 | N |
| 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 | 2022-02-02 | 2022-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-02 | 2022-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-03-14 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-02-02 | 2022-03-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-02 | 2022-03-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-02 | 2022-03-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-02 | 2022-03-14 | 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 | 2022-02-02 | 2022-03-14 | Y |
| 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 | 2022-02-02 | 2022-03-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-02 | 2022-03-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-02 | 2022-03-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-05 | 2020-03-16 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-02-05 | 2020-03-16 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2020-02-05 | 2020-03-16 | 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 | 2020-02-05 | 2020-03-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-05 | 2020-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-05 | 2020-03-16 | 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 | 2020-02-05 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-05 | 2020-03-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-05 | 2020-03-16 | 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 | 2020-02-05 | 2020-03-16 | 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 | 2020-02-05 | 2020-03-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-05 | 2020-03-16 | 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 | 2020-02-05 | 2020-03-16 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-02-05 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-05 | 2020-03-16 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-05 | 2020-03-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-02-05 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-05 | 2020-03-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-05 | 2020-03-16 | N |
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