Inspection Results » Willow Tree Healthcare Center

Health Inspection on December 7, 2018 ^[1]

1. Isolated: Immediate jeopardy to the resident health or safety

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-01-15)

2. Pattern: Actual harm that is not immediate jeopardy

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-01-15)

3. Isolated: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2019-01-15)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-01-15)

4. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-01-31)
   • 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. (Corrected 2019-01-15)

5. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2019-01-15)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-01-15)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2019-01-15)

6. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-01-15)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-01-15)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-01-15)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-01-15)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-01-15)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-01-15)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-01-15)
   • 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 ne (Corrected 2019-01-15)
   • Provide and implement an infection prevention and control program. (Corrected 2019-01-15)
   • Keep residents' personal and medical records private and confidential. (Corrected 2019-01-15)
   • Respond appropriately to all alleged violations. (Corrected 2019-01-15)