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Deficiency Records for Willow Terrace
A list of the most recent deficiencies for Willow Terrace. 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 Terrace. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-17 | 2024-08-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-31 | 2024-07-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-01 | 2024-05-10 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-04-01 | 2024-05-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-01 | 2024-05-10 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-01 | 2024-05-10 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-04-01 | 2024-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-01 | 2024-05-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-01 | 2024-05-10 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-04-01 | 2024-05-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-01 | 2024-05-10 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-04-01 | 2024-05-10 | Y |
| Keep all essential equipment working safely. | Health | 2024-04-01 | 2024-05-10 | Y |
| Install proper backup exit lighting. | Fire Safety | 2024-04-03 | 2024-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-03 | 2024-05-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-03 | 2024-05-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-04-03 | 2024-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-14 | 2024-03-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-08 | 2023-11-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-28 | 2023-11-01 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-20 | 2023-07-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-02 | 2023-07-18 | N |
| 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 | 2023-06-02 | 2023-07-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-02 | 2023-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-02 | 2023-07-18 | 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 | 2023-06-02 | 2023-07-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-06-02 | 2023-07-18 | 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 | 2023-06-02 | 2023-07-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-02 | 2023-07-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-02 | 2023-07-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-02 | 2023-07-18 | 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 | 2023-06-02 | 2023-07-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-02 | 2023-07-18 | 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 | 2023-03-28 | 2023-04-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-06 | 2023-01-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-21 | 2022-08-03 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-07-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-30 | 2022-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-30 | 2022-07-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-24 | 2022-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-07-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-24 | 2022-07-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-24 | 2022-07-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-31 | 2022-06-14 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-31 | 2022-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-31 | 2022-06-14 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-10-07 | 2021-11-11 | Y |
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