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Deficiency Records for Willowcrest Health Services
A list of the most recent deficiencies for Willowcrest 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 Willowcrest 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? |
|---|---|---|---|---|
| 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 | 2024-03-25 | 2024-09-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-25 | 2024-09-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-03-25 | 2024-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-25 | 2024-07-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-29 | 2024-04-26 | 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 | 2024-03-29 | 2024-04-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-29 | 2024-04-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-29 | 2024-04-26 | 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 | 2024-03-29 | 2024-04-26 | 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 | 2024-03-29 | 2024-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-29 | 2024-04-26 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide training in compliance and ethics. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-03-29 | 2024-04-26 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-03-29 | 2024-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-29 | 2024-04-26 | 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 | 2024-03-29 | 2024-04-26 | Y |
| Install resident room doors of proper design and width. | Fire Safety | 2024-03-25 | 2024-04-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-25 | 2024-04-26 | 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 | 2024-03-25 | 2024-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-25 | 2024-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-25 | 2024-04-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-25 | 2024-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-09 | 2023-07-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-09 | 2023-07-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-12 | 2023-02-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-09 | 2023-02-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-11-04 | 2021-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2021-11-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-04 | 2021-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-04 | 2021-11-30 | 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 | 2021-11-04 | 2021-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-03 | 2021-11-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-03 | 2021-11-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-03 | 2021-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-03 | 2021-11-30 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-11-03 | 2021-11-30 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-03-29 | Not Fixed | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-29 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-29 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-29 | Not Fixed | Y |
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