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Deficiency Records for Willow Springs Rehabilitation and Healthcare Ctr
A list of the most recent deficiencies for Willow Springs Rehabilitation and Healthcare Ctr. 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 Willow Springs Rehabilitation and Healthcare Ctr. 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? |
|---|---|---|---|---|
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-07-12 | 2024-10-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-07-12 | 2024-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-12 | 2024-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-12 | 2024-09-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-12 | 2024-09-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-12 | 2024-09-17 | 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 | 2024-07-12 | 2024-09-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-05 | 2024-08-29 | 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 | 2024-07-05 | 2024-08-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-05 | 2024-08-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-12 | 2024-08-29 | 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 | 2024-07-12 | 2024-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-12 | 2024-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-12 | 2024-08-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-12 | 2024-08-29 | Y |
| 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 | 2024-07-12 | 2024-08-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-07-12 | 2024-08-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-12 | 2024-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-12 | 2024-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-12 | 2024-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-12 | 2024-08-26 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-07-12 | 2024-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-12 | 2024-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-12 | 2024-07-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-03 | 2023-11-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-20 | 2023-01-19 | 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 | 2022-12-20 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-20 | 2023-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-01-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-20 | 2023-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-22 | 2022-07-18 | Y |
| 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 | 2022-06-22 | 2022-07-18 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-10-07 | 2020-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-07 | 2020-10-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-10-07 | 2020-10-30 | 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 | 2020-10-07 | 2020-10-26 | N |
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