Inspection Reports for Willows Center

The document is a plan of correction related to a previous investigation survey concluding on 02/08/2024, addressing previously cited deficient practices at the facility.

Willows Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with credible evidence accepted in lieu of an onsite revisit for the investigation survey. The facility is compliant with previously cited deficiencies.

The inspection was conducted to review the facility's compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements based on review of documentation and staff interviews.

An unannounced annual recertification/licensure survey was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rule.

The facility was found out of substantial compliance with multiple deficiencies including resident rights violations, privacy breaches, incomplete nurse aide performance reviews, inaccurate care plans, grievance process failures, medical record inaccuracies, infection control issues, insufficient staffing, and unsafe environment concerns.

The inspection was conducted as a routine survey to assess compliance with federal and state regulations, including fire safety, electrical equipment maintenance, and resident rights.

The facility was found deficient in maintaining an approved automatic sprinkler system, annual flow testing of the fire pump, and electrical testing and maintenance of patient-care equipment. Specific deficiencies included sprinkler heads located too close to light fixtures, lack of annual fire pump testing, and missing inspection documentation for oxygen concentrators and nebulizers.

The inspection was conducted as a complaint investigation survey concluding on 09/27/23, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The facility is in substantial compliance with previously cited deficient practices.

The complaint investigation survey concluded on 09/27/23 with the facility found in substantial compliance and no new deficiencies cited.

The inspection was conducted as a complaint survey concluding on 08/31/2023, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

The complaint survey concluded on 08/31/2023, and the facility was found in substantial compliance with previously cited deficient practices.

An unannounced complaint investigation survey was conducted at Willows Center on 09/27/23 from 8:00 AM to 1:15 PM to investigate complaint #29174.

The complaint was unsubstantiated, but unrelated deficiencies were cited regarding inaccurate medical record documentation of a resident's COVID-19 diagnosis date.

Complaint #29174 was unsubstantiated with unrelated deficiencies cited at F842 regarding resident records and identifiable information.

An unannounced complaint survey was conducted at Willows Center from 08/29/23 to 08/31/23 based on multiple complaints, including allegations of missing items and failure to notify family of resident condition changes.

The survey found deficiencies related to failure to promptly resolve resident grievances and notify responsible parties of changes in resident condition, as well as failure to follow infection control protocols including proper use of PPE in isolation rooms. One complaint was substantiated regarding grievance resolution.

Complaint #27880 was substantiated; other complaints (#28700, #28281, #27183, #28148, #28578, #28683) were unsubstantiated.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

Willows Center was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence without an onsite revisit.

The inspection was conducted to assess compliance with NFPA 101 requirements for smoke barrier doors and to evaluate the facility's adherence to emergency preparedness regulations.

The facility failed to maintain smoke barrier doors in accordance with NFPA 101 standards, as several doors were bowed and exceeded the 1/8 inch gap requirement at meeting edges. The facility was found to be in compliance with emergency preparedness requirements.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Willows Center from June 6-8, 2022.

The survey identified multiple deficiencies including inaccurate Minimum Data Set assessments, incomplete care plan revisions, unlocked medication carts, failure to weigh residents as ordered, improper respiratory care tubing storage, missing nurse aide performance reviews, untimely nurse staffing postings, expired food items and unsanitary kitchen conditions, improper use of psychotropic PRN medications, and incomplete catheter orders.

Complaint #26687 was unsubstantiated with no related or unrelated deficiencies cited.

The inspection was conducted to assess compliance with fire safety codes, building safety, and emergency preparedness requirements at the facility.

The facility was found deficient in multiple areas related to fire safety and building maintenance, including unsealed penetrations in mechanical and smoke barrier rooms, lack of documentation for annual fire pump flow test, bowed smoke barrier doors exceeding fire code requirements, missing junction box covers, and improper use of power strips. The facility provided plans of correction for each deficiency.

The inspection was conducted as a complaint survey concluding on January 10, 2022, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint survey concluding on January 10, 2022, with substantial compliance found and no onsite revisit required.

An unannounced complaint investigation and focused infection control survey was conducted at Willows Center on January 10, 2022, triggered by complaint 25838.

The complaint was unsubstantiated, but the facility failed to report four grievance/concerns related to abuse, neglect, or mistreatment within the required 24-hour timeframe for two residents. The facility did not comply with state law reporting requirements for alleged violations involving abuse, neglect, or mistreatment.

Complaint 25838 was unsubstantiated with an unrelated deficiency cited. Four grievance/concerns related to abuse, neglect, or mistreatment were not reported within 24 hours for Resident #5 and Resident #6. The Administrator confirmed these allegations should have been reported but were not.

Routine inspection of the Willows Center nursing facility to assess compliance with health, safety, and fire protection regulations.

The inspection identified multiple deficiencies related to fire safety, electrical systems, sprinkler systems, means of egress, gas cylinder storage, and emergency preparedness. Corrective actions and re-education plans were provided for each deficiency.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

Willow Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The review included plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at Willows Center from March 1-3, 2021. The survey included observations, record reviews, interviews, and documentation review.

The facility was found deficient in ensuring accurate and complete advance directives documentation for three residents, and in proper labeling and storage of drugs and biologicals, including expired medications and lack of temperature monitoring in medication refrigerators.

Complaint numbers #23953, #24554, #24956, #24047, #24141, #25087, and #24776 were unsubstantiated with no related or unrelated deficiencies cited.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency at Willows Center.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on November 12, 2020.

The facility was found in compliance with infection control regulations and CMS/CDC recommended practices to prepare for COVID-19. No deficiencies were cited.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 22-23, 2020.

The facility was found in compliance with infection control regulations under 42 CFR 483.80, emergency preparedness regulations under 42 CFR 483.73, and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

An unannounced complaint investigation was conducted at Willows Center due to allegations received.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.

Complaint #23656 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia state nursing home licensure rules.

Willows Center was found to be in substantial compliance with federal and state long term care regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The document is a Plan of Correction related to a facility inspection addressing compliance with resident rights and emergency preparedness requirements.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. A deficiency was cited regarding the facility's obligation to inform residents of their rights and services, with a plan of correction provided.

An unannounced annual re-certification and annual re-licensure survey was conducted at Willows Center from 10/28/19 through 10/30/19. Complaint #23057 was investigated concurrently with the annual survey with no related or unrelated deficiencies cited.

The facility was found to have deficiencies including failure to maintain a safe, clean, and comfortable environment in resident rooms, oxygen therapy administered without physician orders, failure to conduct annual performance reviews for nurse aides timely, and improper labeling and storage of medications and biologicals in refrigerators.

Complaint #23057 was investigated concurrently with the annual survey with no related or unrelated deficiencies cited.

The inspection was a routine survey to assess compliance with federal and state regulations including fire safety and resident rights.

The facility was found to have deficiencies related to means of egress being obstructed by wheelchairs and walkers, hazardous areas lacking proper door closures, and sprinkler heads obstructed by light fixtures. Plans of correction were submitted to address these issues.

An unannounced complaint investigation was conducted at Willows Center on 09/03/19 to 09/04/19.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #23059 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced revisit was conducted at Willows Center on 08/12/19 for the complaint investigation survey concluding on 07/02/19.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

Complaint investigation: #22781 and #22507

An unannounced complaint survey was conducted at Willows Center on 07/01/19 to 07/02/19 based on complaints #22507 and #22781, both of which were unsubstantiated with unrelated deficiencies cited.

The facility was found to have multiple deficiencies including failure to maintain a safe environment free from accident hazards such as unsecured steam tables, chemicals, box cutters, oxygen tanks, and razors; failure to maintain complete and accurate medical records; and failure to maintain an infection prevention and control program, specifically lacking proper signage for residents on contact precautions.

Complaint #22507 and Complaint #22781 were both unsubstantiated with unrelated deficiencies cited.

An unannounced complaint investigation was conducted at Willows Center for Complaint Reference #21207.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable federal and state regulations.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

An unannounced complaint investigation was conducted at Willows Center to investigate allegations related to the facility.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was found to be in substantial compliance with applicable federal and state regulations.

Complaint #21422 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

Willows Center was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the Willows Center nursing facility.

The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. One deficiency related to resident rights and notification was cited under tag F156.

Unannounced annual Long Term Care Survey Process and State Licensure Surveys were conducted at Willows Center from September 2018 through October 3, 2018.

The facility was found deficient in multiple areas including grievance resolution documentation, baseline care plan development and summary provision, comprehensive care plan implementation, quality of care including weight monitoring and pressure ulcer prevention, nutrition and hydration management, dialysis care, staffing sufficiency, nurse aide performance evaluations, radiology result notification, food safety, medical record maintenance, infection prevention and control, and quality assurance program effectiveness.

The inspection was conducted to evaluate compliance with NFPA 25 standards for maintenance and testing of the automatic sprinkler and standpipe systems, specifically focusing on the inspection of internal sprinkler system piping and the water storage tank.

The facility failed to provide documented evidence that an inspection of the internal sprinkler piping and water storage tank had been conducted within the past five years as required by NFPA 25. The deficiency potentially affects all residents, staff, and visitors.

Review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 09/28/17.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility is in substantial compliance with the previously cited deficient practices.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Willows Center from 09/25/2017 through 09/28/2017 to assess compliance with federal and state regulations.

The survey identified multiple deficiencies including inaccurate resident assessments, incomplete care plans, inadequate medication monitoring, unsanitary food storage, incomplete controlled substance records, improper infection control practices, unmaintained kitchen equipment, and incomplete medical records documentation.

The inspection was conducted as part of an annual regulatory survey to assess compliance with NFPA 101 fire safety standards and electrical safety requirements.

The facility failed to conduct fire drills on the night shift for the 2nd and 4th quarters as required by NFPA 101, and failed to conduct required inspections and testing of electrical receptacles and patient-care related electrical equipment in accordance with NFPA 99 standards. These deficiencies were acknowledged by the Administrator and Maintenance Supervisor and corrective actions were planned.

The visit was conducted as a complaint investigation following complaints #17954 and #18101, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Willows Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigations #17954 and #18101 concluded on 06/14/17 with the facility found in substantial compliance and no onsite revisit required.

An unannounced complaint survey was conducted at the Willows Center from June 12 to June 14, 2017, based on substantiated complaints #18101 and #17954, involving related and unrelated deficiencies.

The facility was found deficient in multiple areas including medication administration errors, failure to provide special eating utensils, infection control breaches during wound care and catheter care, and incomplete medical records documentation.

Complaint #18101 and Complaint #17954 were substantiated with related deficiencies cited at F333 and F441 respectively, along with unrelated deficiencies at F309, F369, F514, and N941.

The document is a plan of correction related to a previous Quality Indicator and Licensure Survey for Willows Center, addressing previously cited deficient practices.

Willows Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The facility submitted plans of correction and credible evidence accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 08/15/16.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at the Willows Center from August 8, 2016 to August 15, 2016 to assess compliance with federal and state regulations.

The facility was found deficient in multiple areas including housekeeping and maintenance, accident hazards, food sanitation, infection control, and clinical record accuracy. Specific issues included unpainted walls and damaged tiles in resident rooms, unsecured hazardous cleaning wipes, improper food handling by staff, failure to wash hands during medication administration, and inaccurate clinical records documentation.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke tightness of patient room doors, self-closing doors for hazardous areas, and maintenance of portable fire extinguishers.

The facility failed to maintain required smoke tight gaps around patient room doors, had disabled door closers on kitchen storage doors, and lacked required placards above 'K' type fire extinguishers. These deficiencies could affect residents, staff, and visitors.

The document is a plan of correction related to a prior Quality Indicator and Licensure Survey concluding on 06/18/2015, accepted in lieu of an onsite revisit.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke barrier integrity, fire drills, sprinkler system maintenance, and emergency generator testing.

The facility failed to maintain smoke barrier walls with required fire resistance, did not conduct quarterly fire drills on each shift, failed to maintain the sprinkler system in reliable operating condition, and did not properly maintain and test the emergency generator battery electrolyte fluid.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Willows Center from June 15, 2015 through June 18, 2015 to assess compliance with federal and state regulations.

The survey identified multiple deficiencies including failure to provide correct Medicare termination notices, improper conveyance of personal funds upon death, inadequate housekeeping and maintenance, failure to report and investigate allegations of neglect, lack of resident participation in care planning, delayed pharmacist recommendations to physicians, improper storage and labeling of medications, and infection control breaches during incontinence care.

The document is a plan of correction submitted by Willows Center following a Quality Indicator and Licensure Survey concluding on 02/18/14, accepted in lieu of an onsite revisit.

Willows Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke barrier integrity, smoking regulations, and electrical wiring safety in the facility.

The facility failed to maintain smoke barrier walls with the required fire resistance rating, used inappropriate materials as ashtrays in smoking areas, and had electrical wiring issues including a thermostat installed too close to a water source and a laundry room receptacle lacking ground fault protection.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Willow Center from February 10, 2014 through February 18, 2014.

The survey identified multiple deficiencies including ineffective housekeeping and maintenance services affecting multiple resident rooms, inaccurate resident assessments related to prognosis, failure to update care plans to reflect changes in resuscitation status, incomplete assessment and treatment of pressure ulcers, and failure to complete annual performance reviews for nursing assistants.

An onsite revisit was conducted on 12/18/13 for the complaint 13238 / 8906 completed on 10/18/13.

The facility was found to be in substantial compliance with all previously cited deficient practices and meets the requirements for a skilled nursing facility as described in subsections (b), (c), and (d) of section 1819 of the Social Security Act.

Complaint 13238 / 8906 was investigated and the facility was found to be in substantial compliance.

The inspection was conducted as a substantiated complaint investigation related to allegations of neglect and failure to provide adequate care and supervision to residents.

The facility was found to have failed in multiple areas including neglect leading to a resident fall with serious injury, contradictory care plan interventions, failure to implement care plan interventions, and failure to maintain a safe environment to prevent accidents. Specific residents were identified with issues such as falls, skin tears, and lack of proper supervision.

The complaint investigation was substantiated with citations related to neglect and failure to provide adequate care and supervision, including a resident fall resulting in serious injury.

The inspection was conducted as a complaint investigation based on complaint reference 7544 / 13011.

The complaint was found to be unsubstantiated with no citations issued.

Complaint reference 7544 / 13011 was investigated and found to be unsubstantiated with no citations.

The document is a plan of correction related to deficiencies identified during a prior inspection at Willows Center.

The facility was cited for failure to properly inform residents of their rights and services as required by regulation 483.10(b)(5)-(10).

Routine QIS survey conducted from 7/23/12 through 7/26/12 to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to notify a resident of roommate changes, inadequate meaningful activities for a blind resident, failure to develop and revise comprehensive care plans, failure to implement care plans for psychoactive medication monitoring, and failure to ensure drug regimens were free from unnecessary drugs.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on door openings in smoke barriers and medical gas storage and administration areas.

The facility failed to ensure that fire doors in smoke barriers properly closed in two wings of the building, affecting the West Hall and Service Hall. Additionally, oxygen storage was found to be non-compliant with NFPA 99 standards, being stored next to steel doors and below a window, violating the requirement that oxygen storage be at least 20 feet from doors or windows.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for the Willows Center nursing facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).

The inspection was conducted as a complaint investigation (#11287) to determine compliance with care planning and safety requirements for residents, specifically focusing on Resident #54.

The facility failed to revise the care plan for Resident #54 after changes in her health condition and treatment plan, and failed to ensure adequate safety measures were in place to prevent falls. Interventions initially implemented were not reinstated after hospitalization, leading to multiple falls.

Complaint investigation #11287 was substantiated with citation at F323d. The complaint involved failure to revise care plans and ensure safety measures for Resident #54, who experienced multiple falls and injuries.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding electrical wiring and equipment in patient care areas.

The facility was found to have relocatable power taps (electrical power strips) in use within patient care areas, which are not intended for use in general or critical patient care areas according to the National Electrical Code. Specific violations were observed in multiple resident rooms.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, accident prevention, and quality assurance processes.

The facility failed to ensure that all incident/accident reports were thoroughly investigated, particularly those not involving resident falls, affecting multiple residents. The quality assessment and assurance committee did not recognize these deficiencies, and investigation forms were only completed for incidents of unknown origin, contrary to facility policy.

Annual inspection of the facility to assess compliance with life safety codes, fire safety standards, and regulatory requirements.

The facility was found deficient in multiple areas including corridor door closures, smoke barrier fire resistance, exit door locking mechanisms, fire alarm system maintenance, sprinkler system testing, and range hood extinguishing system inspections.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, comprehensive care plans, quality of care, sanitary conditions, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, improper medication administration techniques, failure to use proper transfer techniques, and unsanitary food preparation and storage practices. Several deficiencies were cited with severity levels ranging from C to F.

The inspection was conducted as a complaint investigation referenced as #2-7119.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7119 was unsubstantiated with no deficiencies cited.

The visit was a paper revisit to follow up on previous deficiencies.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. No specific findings beyond the initial comments are detailed in the provided page.

The inspection was conducted in response to complaint references #2-7108 and #2-7109 to investigate alleged deficiencies at the facility.

The facility failed to complete an incident report when a bruise of unknown origin was found on a resident's leg. The complaint was unsubstantiated but unrelated deficiencies were cited, including failure to document incidents properly.

Complaint references #2-7108 and #2-7109 were investigated and found unsubstantiated; however, unrelated deficiencies were cited regarding incident reporting.

The visit was a paper revisit to review previous deficiencies and verify corrections.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements, but no specific deficiencies or severity levels are detailed in this excerpt.

The inspection was conducted as a substantiated complaint investigation concurrently with the facility's annual Federal Medicare/Medicaid certification survey and State licensure inspection.

The facility was found deficient in multiple areas including failure to immediately report all allegations of abuse/neglect, failure to maintain quality of life by neglecting resident care needs, inadequate accommodation of resident needs related to shower room temperature, failure to post actual nurse staffing data, unsanitary food preparation and service practices, and unsafe environmental conditions such as improper use of a battery charger in a resident's room.

Complaint reference #2-7077. The complaint was substantiated with deficiencies cited related to abuse/neglect reporting failures.

Routine inspection of the facility's compliance with life safety codes and regulatory requirements.

The facility was found deficient in multiple life safety code areas including corridor doors held open with wedges, lack of proper exit signage, unsealed smoke barrier penetrations, hazardous room doors not self-closing, blocked egress paths, incomplete fire drill documentation, failure to maintain sprinkler system and fire pump records, lack of metal containers with self-closing covers in smoking areas, incomplete generator testing and maintenance records, and electrical receptacles not meeting code requirements.

The inspection was conducted as a complaint investigation based on complaint reference #2-6239.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-6239 was unsubstantiated with no deficiencies cited.

The visit was a paper revisit to follow up on previously identified deficiencies.

The document contains a statement of deficiencies related to resident rights and notification requirements, but no detailed findings or severity levels are provided.

The inspection was conducted in response to complaint references #2-6189, #2-6191 (unsubstantiated with unrelated deficiencies) and #2-6213 (substantiated with deficiencies cited).

The inspection found medication administration errors involving one resident where an eye drop was omitted and the wrong medication was initialed on the MAR. Additionally, two nursing assistants were found to have worked on expired registrations from January to August 2006, potentially affecting all residents they cared for.

Complaint references #2-6189 and #2-6191 were unsubstantiated with unrelated deficiencies cited. Complaint reference #2-6213 was substantiated with deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-6143.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-6143 was unsubstantiated with no deficiencies cited.

This document is a plan of correction submitted in response to deficiencies identified during a prior inspection.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as well as providing written descriptions of legal rights.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to monitor dialysis graft patency, improper measurement of gastrostomy flush volumes, inadequate oral and hand hygiene for residents, unsanitary food preparation conditions, improper linen handling, malfunctioning nurse call system, and incomplete clinical records documentation.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding the maintenance and inspection of the facility's automatic sprinkler system.

The facility failed to maintain the sprinkler system in accordance with NFPA 25 and 13 standards. Observations included two corroded sprinkler heads in the kitchen dishwashing area and storage placed within six inches of a sprinkler head in the laundry folding room.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the Willows Center nursing facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation referenced as #2-5300, substantiating deficiencies related to resident privacy and confidentiality.

The facility failed to ensure that Resident #69's confidential health information was only released to persons authorized by the resident. The attending physician disclosed health information to a family member not authorized by the resident, violating privacy rights.

Complaint reference #2-5300 was substantiated with deficiencies cited related to privacy and confidentiality violations involving Resident #69.

The visit was a paper revisit to follow up on previous deficiencies.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements, with no detailed findings provided in this excerpt.

The inspection was conducted as a comprehensive annual survey of the nursing facility to assess compliance with federal regulations and quality of care standards.

The facility was found deficient in multiple areas including failure to ensure residents' rights regarding capacity determinations, inadequate maintenance of equipment, inaccurate enteral feeding administration, prolonged use of antipsychotic medication without dose reduction, unsafe physical environment conditions, and incomplete physician order documentation and signatures.

The inspection was conducted to assess compliance with various life safety codes and regulatory standards related to fire safety, emergency procedures, medical gas storage, electrical equipment, and sprinkler systems at the facility.

The facility was found to have multiple deficiencies including unsealed smoke barrier penetrations, failure to maintain self-closing doors, blocked egress paths, inadequate fire drill procedures, sprinkler system maintenance issues, improper oxygen cylinder storage, unsecured electrical disconnects, and failure to notify authorities during sprinkler and fire alarm system shutdowns.

The inspection was conducted as a complaint investigation referenced as #2-4245.

The complaint was substantiated based on record review, but no deficiencies were cited.

Complaint reference: #2-4245. Substantiated record complaint with no deficiencies cited.

The inspection was conducted in response to two complaint references: 2-4143 and 2-4153.

The complaint referenced by 2-4143 was unsubstantiated with no deficiencies cited. The complaint referenced by 2-4153 was substantiated but no deficiencies were cited.

Complaint reference 2-4143 was unsubstantiated with no deficiencies cited. Complaint reference 2-4153 was substantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-4180, which was substantiated with deficiencies cited.

The facility failed to maintain safe hot water temperatures at hand sinks in resident care areas, with recorded temperatures exceeding the maximum allowable 110 degrees Fahrenheit, violating West Virginia Licensure Regulations for nursing homes.

Complaint reference #2-4180 was substantiated with deficiencies cited related to unsafe hot water temperatures.

The inspection was conducted as a substantiated complaint investigation referenced as #2-4085.

The facility was found deficient in notifying a resident's legal health care representative about a chest x-ray and its results, failing to monitor two residents with MRSA for antibiotic effectiveness and temperature, and inadequate handwashing practices by staff observed during the visit.

Complaint reference #2-4085 was substantiated with deficiencies cited.

Annual inspection of Willows Center nursing facility to assess compliance with federal regulations including resident rights, quality of care, resident assessments, medication administration, infection control, and staffing requirements.

The facility was found deficient in multiple areas including failure to document resident capacity determinations, inadequate removal of lap buddies during meals, improper resident exposure during showering, inaccessible overbed tables hindering resident independence, incomplete resident assessment protocol documentation, failure to check gastrostomy tube placement before medication administration, improper insulin injection technique, use of antipsychotic medication without adequate indication or monitoring, failure to post nursing staffing publicly, and lapses in infection control practices.

The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically focusing on the maintenance and testing of the facility's automatic sprinkler system fire pump.

The facility failed to maintain documentation for the previous twelve months indicating that the sprinkler system fire pump electric motor was exercised weekly for a minimum of ten minutes as required by NFPA 25 standards.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, quality of life, quality of care, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to allow residents to choose their wake-up time and meal location, inadequate care for a resident with significant weight loss including improper positioning and incomplete meal trays, failure to follow weighing procedures, and failure to prevent wound infestation by maggots in another resident. The facility was cited for deficiencies in resident rights, quality of life, quality of care, and infection control.

The inspection was conducted as a standard annual survey to assess compliance with federal nursing home participation requirements.

Based on observation, medical record review, and interviews, the facility was found to be in substantial compliance with federal nursing home participation requirements.

Inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding the maintenance of smoke barrier doors.

The facility was found deficient in maintaining smoke barrier doors to resist the passage of smoke due to warped doors creating excessive space at the astragal strip, which compromises smoke containment.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, quality of life, quality of care, and physical environment.

The facility was found deficient in maintaining resident dignity due to inappropriate signage above beds, failed to provide adequate supervision to prevent falls resulting in a fractured hip for one resident, and had physical environment issues including mold and mildew in the shower area.

The inspection was conducted as a Life Safety Code Survey and Environmental Survey to determine compliance with NFPA 101, Life Safety Code, 1981, and 483.70 Physical Environment provisions.

The facility was found to be without waivers and in compliance with the Life Safety Code and Environmental Survey requirements based on documentation review, staff interviews, observations, and performance testing.

The inspection was conducted in response to complaint #21221 regarding staff treatment of residents and quality of care issues.

The facility failed to report or thoroughly investigate an incident of unknown origin involving a bruise on Resident #37. Additionally, the facility failed to ensure that 13 incontinent residents received necessary personal hygiene care, with observations of residents being wet or soiled and staff not adhering to the required two-hour check schedule.

Complaint #21221 involved allegations of staff mistreatment and neglect, specifically failure to report an injury of unknown origin and inadequate personal hygiene care for incontinent residents. The complaint was substantiated based on findings.

The inspection was conducted as a standard annual survey to assess compliance with federal regulations regarding resident rights, quality of life, infection control, physical environment, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to maintain resident dignity and reasonable accommodations for resident #8, improper infection control practices related to resident #33, inadequate visual privacy in resident rooms, and unsafe, unsanitary, and non-functional physical environment conditions such as damaged doors and shower areas.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to resident rights and facility safety.

The facility was found deficient in maintaining corridor doors serving hazardous areas to properly latch, using furnishings of highly flammable construction such as a wicker waste basket in the physical therapy room, and preventing the use of combustible wastebaskets in resident rooms.

The inspection was conducted as a complaint investigation related to concerns about resident care and supervision at the facility.

The facility failed to develop an adequate care plan for Resident #104 regarding photosensitivity precautions, resulting in a sunburn. Additionally, the facility failed to provide adequate supervision to prevent Resident #104 from sunburn and Resident #50 from eloping despite known risks and interventions.

Complaint #2-0152 triggered the investigation. The complaint involved inadequate care planning and supervision leading to harm and safety risks for Residents #104 and #50. The complaint was substantiated based on findings.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire rated construction, smoke barrier doors, and sprinkler system maintenance.

The facility was found to have unsealed penetrations in smoke barrier walls, smoke barrier doors that failed to close completely, and a sprinkler system fire pump that was not exercised weekly as required.

The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, quality of life, resident assessment, dietary services, infection control, and clinical record maintenance.

The facility was found deficient in multiple areas including failure to obtain required statements of incapacity for residents with medical powers of attorney, inadequate activity programming, failure to meet professional standards in resident services, unsanitary food storage, inadequate infection control practices, and incomplete clinical records for some residents.

The inspection was conducted to assess compliance with physical environment standards, including equipment maintenance and resident call system functionality.

The facility failed to maintain safe hot water temperatures exceeding allowed maximums and had multiple resident call system failures in various rooms.

The document is a plan of correction submitted in response to deficiencies cited during a prior inspection at Willows Center.

The facility was cited for failure to maintain clinical records on each resident in accordance with accepted professional standards, including completeness, accuracy, accessibility, and systematic organization.

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