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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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-31 | 2024-10-27 | 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 | 2024-07-31 | 2024-10-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-31 | 2024-10-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-02 | 2024-07-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-02 | 2024-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-02 | 2024-07-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-07-02 | 2024-07-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-02 | 2024-07-17 | 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 | 2024-07-02 | 2024-07-17 | 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 | 2024-07-02 | 2024-07-17 | 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 | 2024-07-02 | 2024-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-02 | 2024-07-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-02 | 2024-07-17 | N |
| 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 |
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