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Willow Crest Nursing Pavilion

Inspection Results

Nursing Homes Illinois Sandwich Willow Crest Nursing Pavilion

Willow Crest Nursing Pavilion has been cited for a total of 87 deficiencies in our most recent deficiency data, which typically covers 3 health and fire safety surveys.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Willow Crest Nursing Pavilion.

There are 711 nursing homes in Illinois with a total of 34,918 deficiencies resulting in an average of 49.11 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, and Date of Correction
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
08-16-2020
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
08-26-2020
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
08-26-2020
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
08-20-2020
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
04-03-2020
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-03-2020
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-03-2020
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-03-2020
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-03-2020
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
04-03-2020
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
04-03-2020
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
04-03-2020
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
Corrected:
04-03-2020
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
04-03-2020
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.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
03-06-2020
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
10-25-2019
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
08-13-2019
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
08-13-2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
07-26-2019
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
05-07-2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
05-07-2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
05-07-2019
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-07-2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-07-2019
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-07-2019
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-07-2019
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-07-2019
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
05-07-2019
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
Corrected:
05-07-2019
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
05-07-2019
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
03-14-2019
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
03-04-2019
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
Corrected:
03-04-2019
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
03-04-2019
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
12-07-2018
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
12-07-2018
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
12-07-2018
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
Corrected:
11-01-2018
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
10-01-2018
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
10-01-2018
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
G
Corrected:
09-07-2018
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
Corrected:
09-07-2018
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
Corrected:
09-07-2018
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
06-14-2018
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
04-20-2018
Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
04-20-2018
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
04-20-2018
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
04-20-2018
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-20-2018
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-20-2018
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-20-2018
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
Corrected:
04-20-2018
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
Corrected:
04-13-2018
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
Corrected:
05-07-2018
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
04-20-2018
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
05-07-2018
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
Corrected:
04-20-2018
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
Corrected:
04-20-2018
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
Corrected:
04-20-2018
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
Corrected:
04-20-2018
Develop and maintain an Emergency Preparedness Program (EP).
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Develop Emergency Preparedness policies and procedures.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Address subsistence needs for staff and patients.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Establish policies and procedures for sheltering.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Develop a communication plan.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Establish emergency prep training and testing.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Establish staff and initial training requirements.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-24-2020
Implement emergency and standby power systems.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
09-21-2020
Have properly located and lighted "Exit" signs.
Category:
Egress Deficiencies
Scope:
F
Corrected:
09-21-2020
Have an enclosure around a vertical opening shaft.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
09-21-2020
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
09-21-2020
Have approved installation, maintenance and testing program for fire alarm systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
09-21-2020
Inspect, test, and maintain automatic sprinkler systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
09-21-2020
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
09-21-2020
Have simulated fire drills held at unexpected times.
Category:
Miscellaneous Deficiencies
Scope:
C
Corrected:
09-21-2020
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
05-20-2019
Have approved installation, maintenance and testing program for fire alarm systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
05-20-2019
Provide a written emergency evacuation plan.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
05-20-2019
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Category:
Miscellaneous Deficiencies
Scope:
E
Corrected:
05-20-2019
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
05-20-2019
Have proper power supply for life support equipment.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
05-20-2019
Have generator or other power source capable of supplying service within 10 seconds.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
05-20-2019
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.
Category:
Egress Deficiencies
Scope:
E
Corrected:
03-22-2018
Have exits that are accessible at all times.
Category:
Egress Deficiencies
Scope:
E
Corrected:
03-21-2018
Provide properly protected cooking facilities.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
03-20-2018
Have simulated fire drills held at unexpected times.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
03-17-2018
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Category:
Electrical Deficiencies
Scope:
F
Corrected:
03-17-2018

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Willow Crest Nursing Pavilion

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