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Deficiency Records for Willow Haven Nursing Home
A list of the most recent deficiencies for Willow Haven Nursing Home. 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 Haven Nursing Home. 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? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-04 | 2024-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-04 | 2024-10-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2023-12-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-01 | 2023-03-25 | 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 | 2023-02-01 | 2023-03-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-01 | 2023-03-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-01 | 2023-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-01 | 2023-03-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-01 | 2023-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-01 | 2023-03-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-01 | 2023-03-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-01 | 2023-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-03-25 | 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 | 2023-02-01 | 2023-03-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-01 | 2023-03-25 | 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 | 2023-02-01 | 2023-03-25 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-01 | 2023-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-01 | 2023-03-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-01 | 2023-03-25 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-02-01 | 2023-03-25 | 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 | 2023-02-02 | 2023-03-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-02 | 2023-03-02 | 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 | 2019-11-18 | 2019-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-18 | 2019-11-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-18 | 2019-11-19 | 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 | 2019-11-13 | 2019-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-13 | 2019-11-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-11-13 | 2019-11-18 | N |
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