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Deficiency Records for Willow Valley Center For Nursing and Rehab

A list of the most recent deficiencies for Willow Valley Center For Nursing and Rehab. 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 Valley Center For Nursing and Rehab. 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-07-02 2024-07-17 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-07-02 2024-07-17 Y
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2024-07-02 2024-07-17 Y
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2024-07-02 2024-07-17 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 2024-07-02 2024-07-17 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 2024-07-02 2024-07-17 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-07-02 2024-07-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-07-02 2024-07-17 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-07-02 2024-07-17 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-07-02 2024-07-17 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-07-02 2024-07-17 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-07-02 2024-07-17 Y
Ensure medication error rates are not 5 percent or greater. Health 2024-07-02 2024-07-17 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-07-02 2024-07-17 Y
Put firmly secured handrails on each side of hallways. Health 2024-07-02 2024-07-17 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-11-21 2023-12-19 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-09-06 2023-12-01 N
Install an approved automatic sprinkler system. Fire Safety 2023-09-06 2023-12-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-06 2023-12-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-09-06 2023-12-01 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-21 2023-11-21 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-08-07 2023-09-06 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-08-07 2023-09-06 N
Assess the resident when there is a significant change in condition Health 2023-08-07 2023-09-06 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2023-08-07 2023-09-06 N
Ensure each resident receives an accurate assessment. Health 2023-08-07 2023-09-06 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 2023-08-07 2023-09-06 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-08-07 2023-09-06 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-08-07 2023-09-06 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-08-07 2023-08-07 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-07 2023-08-07 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-08-07 2023-08-07 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-02-17 2023-03-06 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-02-17 2023-03-06 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-10-28 2023-03-06 Y
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 2023-01-06 2023-02-17 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-10-28 2023-02-17 Y
Respond appropriately to all alleged violations. Health 2022-10-28 2023-01-06 Y
Ensure that residents are free from significant medication errors. Health 2022-10-28 2023-01-06 Y
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2022-08-16 2022-08-30 Y
Use approved construction type or materials. Fire Safety 2022-06-23 2022-07-22 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 2022-06-23 2022-07-22 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 2022-06-23 2022-07-22 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2022-06-23 2022-07-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-06-23 2022-07-22 N
Have proper medical gas storage and administration areas. Fire Safety 2022-06-23 2022-07-22 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2022-05-24 2022-06-21 N
Ensure each resident receives an accurate assessment. Health 2022-05-24 2022-06-21 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-05-24 2022-06-21 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-05-24 2022-06-21 N
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 2022-05-24 2022-06-21 N
Post nurse staffing information every day. Health 2022-05-24 2022-06-21 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 2022-05-24 2022-06-21 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2022-05-24 2022-06-21 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-05-24 2022-06-21 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-05-24 2022-06-21 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-05-24 2022-06-21 N
Ensure staff are vaccinated for COVID-19 Health 2022-05-24 2022-06-21 N
Keep all essential equipment working safely. Health 2022-05-24 2022-06-21 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-05-24 2022-06-21 Y
Reasonably accommodate the needs and preferences of each resident. Health 2022-05-24 2022-06-21 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-05-24 2022-06-21 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-05-24 2022-06-21 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-24 2022-06-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-24 2022-06-21 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-05-24 2022-06-21 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 2022-05-24 2022-06-21 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-05-24 2022-06-21 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-05-24 2022-06-21 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-04-27 2021-05-19 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-04-27 2021-05-19 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2021-04-27 2021-05-19 N
Ensure each resident receives an accurate assessment. Health 2021-04-27 2021-05-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-04-27 2021-05-19 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-04-27 2021-05-19 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 2021-04-27 2021-05-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-27 2021-05-19 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 2021-05-13 2021-05-13 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2021-05-13 2021-05-13 N

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