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Deficiency Records for Willow Tree Healthcare Center
A list of the most recent deficiencies for Willow Tree Healthcare Center. 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 Tree Healthcare Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-19 | 2024-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-19 | 2024-03-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-19 | 2024-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-19 | 2024-03-01 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-19 | 2024-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-20 | 2023-10-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-20 | 2023-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-20 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-20 | 2023-10-20 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-05-03 | 2023-06-21 | 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 | 2023-05-03 | 2023-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-03 | 2023-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-06-16 | 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 | 2023-05-03 | 2023-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-03 | 2023-06-16 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-06-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-03 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-03 | 2023-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-03 | 2023-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-03 | 2023-06-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-03 | 2023-06-16 | Y |
| 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 | 2023-05-03 | 2023-06-16 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-03 | 2023-06-16 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2023-05-03 | 2023-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-03 | 2023-06-16 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-02 | 2022-03-31 | 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 | 2022-03-02 | 2022-03-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-02 | 2022-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-02 | 2022-03-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-02 | 2022-03-31 | 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 | 2022-03-02 | 2022-03-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-02 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-02 | 2022-03-31 | N |
| 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 | 2022-03-02 | 2022-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-03-31 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-03-02 | 2022-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-26 | 2020-03-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-26 | 2020-03-25 | N |
| 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 | 2020-02-26 | 2020-03-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-26 | 2020-03-25 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-26 | 2020-03-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-26 | 2020-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-26 | 2020-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-03-25 | 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 | 2020-02-26 | 2020-03-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-26 | 2020-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-26 | 2020-03-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-26 | 2020-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-26 | 2020-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-25 | 2020-03-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-25 | 2020-03-16 | N |
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