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Deficiency Records for Willowdale Health Services
A list of the most recent deficiencies for Willowdale Health Services. 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 Willowdale Health Services. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-01-22 | 2025-02-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-02 | 2024-11-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-10-02 | 2024-11-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-10-02 | 2024-11-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-02 | 2024-11-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-10-02 | 2024-11-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-10-02 | 2024-11-02 | 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 | 2024-10-02 | 2024-11-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-10-01 | 2024-11-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-01 | 2024-11-02 | 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 | 2023-11-08 | 2023-12-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-08 | 2023-12-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-08 | 2023-12-08 | 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 | 2023-11-08 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2023-12-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-12 | 2022-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-12 | 2022-11-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-12 | 2022-11-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-11 | 2022-11-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-11 | 2022-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-11 | 2022-11-12 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-10-11 | 2022-11-12 | N |
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