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Deficiency Records for Willows Post Acute
A list of the most recent deficiencies for Willows Post Acute. 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 Willows Post Acute. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-04-09 | 2024-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-09 | 2024-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-09 | 2024-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-09 | 2024-05-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-04-09 | 2024-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-09 | 2024-05-01 | 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 | 2024-04-04 | 2024-04-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-04 | 2024-04-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-04-04 | 2024-04-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-04 | 2024-04-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-04-04 | 2024-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-04 | 2024-04-28 | 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 | 2024-04-04 | 2024-04-28 | N |
| Provide or obtain dental services for each resident. | Health | 2024-04-04 | 2024-04-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-04-04 | 2024-04-28 | 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 | 2024-04-04 | 2024-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-04 | 2024-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-04 | 2024-04-28 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-01 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-11 | 2022-11-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-11 | 2022-11-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-07 | 2022-04-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-07 | 2022-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-04-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-07 | 2022-04-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-04 | 2021-12-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2021-12-07 | 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 | 2021-12-07 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-04 | 2021-12-07 | Y |
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