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Deficiency Records for The Willows at Gretna
A list of the most recent deficiencies for The Willows at Gretna. 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 The Willows at Gretna. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-02 | 2024-05-14 | 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 | 2024-05-02 | 2024-05-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-29 | 2024-02-16 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-15 | 2023-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-15 | 2023-09-28 | 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 | 2023-08-15 | 2023-09-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-15 | 2023-09-28 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-14 | 2023-09-28 | 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 | 2023-08-14 | 2023-09-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-14 | 2023-09-28 | 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 | 2023-08-14 | 2023-09-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-08-14 | 2023-09-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-28 | 2023-01-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-15 | 2023-01-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-15 | 2023-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-01-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-15 | 2023-01-04 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-15 | 2023-01-04 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2022-06-01 | 2022-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-01 | 2022-08-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-01 | 2022-08-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-01 | 2022-08-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-01 | 2022-06-29 | 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 | 2022-06-01 | 2022-06-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-06-01 | 2022-06-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-02 | 2022-06-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-02 | 2022-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-02 | 2022-06-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-29 | 2020-10-30 | 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 | 2020-09-29 | 2020-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-09-29 | 2020-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-09-29 | 2020-10-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-09-30 | 2020-10-14 | N |
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