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Deficiency Records for Willow Creek Healthcare Center
A list of the most recent deficiencies for Willow Creek 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 Creek 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-07 | 2024-07-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-07 | 2024-07-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-21 | 2024-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-21 | 2024-07-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-29 | 2024-06-17 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-05-14 | 2024-05-20 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-07 | 2024-03-25 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-07 | 2024-03-25 | 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 | 2024-03-07 | 2024-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-03-25 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-07 | 2024-03-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-13 | 2024-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-06 | 2023-10-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-30 | 2023-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-09 | 2023-08-20 | Y |
| 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 | 2023-08-09 | 2023-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-08-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-03 | 2023-05-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-29 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-17 | 2022-06-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-17 | 2019-08-07 | 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 | 2019-05-17 | 2019-08-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-17 | 2019-08-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-17 | 2019-08-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-08-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-17 | 2019-08-07 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-17 | 2019-08-07 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-05-17 | 2019-08-07 | 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 | 2019-05-17 | 2019-08-07 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-17 | 2019-08-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-05-17 | 2019-08-07 | N |
| 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 | 2019-05-17 | 2019-08-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-17 | 2019-08-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-17 | 2019-08-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-17 | 2019-08-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-17 | 2019-08-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-17 | 2019-08-07 | N |
| Keep all essential equipment working safely. | Health | 2019-05-17 | 2019-08-07 | N |
| 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 | 2019-06-04 | 2019-07-09 | 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 | 2019-06-04 | 2019-07-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-04 | 2019-07-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-04 | 2019-07-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-04 | 2019-07-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-04 | 2019-07-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-04 | 2019-07-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-03 | 2018-07-26 | 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 | 2018-05-03 | 2018-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-03 | 2018-07-26 | 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 | 2018-05-03 | 2018-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-03 | 2018-07-26 | N |
| Keep all essential equipment working safely. | Health | 2018-05-03 | 2018-07-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-29 | 2018-06-14 | 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 | 2018-05-29 | 2018-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-29 | 2018-06-14 | N |
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