Inspection visit
Inspection
27 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 27 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0563
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, visitation signage, interview, and review of the Centers for Medicare and Medicaid Services
(CMS) guidance, the facility failed to ensure residents were allowed visitation. This affected all of the
residents who resided in the facility. The census was 45.
Residents Affected - Many
Findings include:
Review of the coronavirus website for the county positivity rate for Covid-19 revealed as of 06/22/21, the
positivity rate in [NAME] county was 1.9%.
Review of the list of vaccinated residents in the facility, dated 06/28/21, revealed 22 of 45 residents, or 48
percent, had been vaccinated.
Observation of signs on the front door to the entrance of the facility on 06/28/21 at 9:00 A.M. revealed
visitation was not allowed unless it was scheduled through the facility.
Observation of the Resident Council Meeting conducted on 06/28/21 at 10:57 A.M. by Activities Director
(AD) #68 revealed there were questions about visitation and the response was when the residents received
more vaccinations the facility would be opening up for more visitation.
Interview with Resident #22 on 06/28/21 at 3:30 P.M. revealed the facility was not conducting visitation right
now. The families could stand outside the window if they wanted to visit with the residents. There was
renovations in the facility and visitors are not allowed in to visit. She revealed she hadn't seen her family in
over a year.
Interview with AD #68 on 06/29/21 at 7:36 A.M. revealed there were supervised visits in the lobby with the
receptionist and it was conducted on Tuesdays and Thursdays due to the low vaccination rate in the facility.
The appointments could be made at 1:30, 2:30, or 3:30 P.M. and they lasted 30 minutes. Since the
renovations have started in the facility, the visitation is limited to one day a week right now.
Interview with the Receptionist #29 on 06/29/21 at 1:11 P.M. revealed the families schedule appointments
and make sure one day of the week, when the construction wasn't going on, visitation was set up in the
main lobby on Thursdays. She stated visitors could not go to the resident rooms due to the low vaccination
rate of the residents. The families and residents are encouraged to receive their vaccinations so the facility
could be opened up for visitation. She revealed during the visitation it was kind of supervised to make sure
the families don't touch anybody. The visit has to be six feet
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
365648
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0563
apart, there could be no hugging or touching, or exchange any items during the visit.
Level of Harm - Minimal harm
or potential for actual harm
Observation of visitation on 07/01/21 at 1:31 P.M. revealed there were four tables with chairs around them
placed six feet apart. Scheduler #8 was monitoring the visitation. She was in and out of the room. At 1:57
P.M. the Scheduler told the visitors they had two minutes left for the visit and they had to leave to ensure the
next visitation was set up for 2:30 P.M. At 2:00 P.M. the Scheduler told the residents they couldn't touch
anything in the room and to go back to their rooms.
Residents Affected - Many
Interview with Resident #20's family member on 07/01/21 at 1:58 P.M. revealed the families were told they
could only visit once a week due to renovations. They were told they couldn't hug or touch the residents or
hand them anything on the visit. If the policy had changed the families hadn't been informed of the change.
Interview with the Administrator on 07/01/21 at 3:15 P.M. revealed the facility only allowed visits on
Tuesdays and Thursdays due to the renovations and the low vaccination rates of the residents. She
revealed she was following the guidance from the Department of Aging that was out of date. She stated no
one in the building had Covid-19 and no residents were on quarantine.
Review of CMS QSO memo 20-39, revised on 04/27/21, stated under Indoor Visitation:
Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status),
except for a few circumstances when visitation should be limited due to a high risk of COVID-19
transmission (note: compassionate care visits should be permitted at all times). These scenarios include
limiting indoor visitation for:
·
Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of
residents in the facility are fully vaccinated;
·
Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met two
criteria to discontinue Transmission-Based Precautions; or
·
Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from
quarantine.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record
review revealed Resident #22 was admitted on [DATE]. Medical diagnoses included hemiplegia and
hemiparesis following cerebral infarction affecting left non-dominant side, diabetes, rheumatoid arthritis,
diabetes, atrial fibrillation, morbid obesity, chronic kidney disease, anxiety, depression, and unsteadiness on
her feet.
Review of quarterly MDS dated [DATE] revealed Resident #22 was cognitively intact.
Review of physician orders for Resident #22 revealed she was prescribed Losartan 100 milligram (mg),
Metoprolol 25 mg ER and Diltiazem Extended Release (ER) 180 mg and for high blood pressure, Lipitor 10
mg for high cholesterol, Fluoxetine 40 mg for depression, and Synthroid 125 micrograms (mcg) for low
thyroid.
Review of the revised care plans, dated 04/28/21, revealed no plan of care for high cholesterol,
hypothyroidism, depression and hypertension.
During interview on 07/06/21 at 2:11 P.M. , MDS Licensed Practical Nurse (LPN) #54 verified there were no
care plans for the use of the above medications.
Review of the facility policy titled Care Plans, dated 04/01/09, revealed care plans shall incorporate goals
and objectives that lead to the residents highest obtainable level of independence.
1.
Care plan goals and objectives are defined as the desired outcome for a specific resident problem.
2.
When goals and objectives are not achieved, the residents clinical record will be documented as to why the
results were not achieved and what new goals and objectives have been established. Care plans will be
modified accordingly.
3.
Care plan goals and objectives are derived from information contained in the residents comprehensive
assessment and:
a.
Are resident oriented;
b.
Are behaviorally stated;
c.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Are measurable; and
Level of Harm - Minimal harm
or potential for actual harm
d.
Contain timetables to meet the residents needs in accordance with the comprehensive assessment.
Residents Affected - Few
4.
Goals and objectives are entered on the residents care plan so that all disciplines have access to such
information and are able to report whether or not the desired outcomes are being achieved.
5.
Goals and objectives are reviewed and/or revised:
a.
When there has been a significant change in the resident's condition;
b.
When the desired outcome has not been achieved;
c.
When the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and
d.
At least quarterly.
6.
The resident has the right to refuse to participate in establishing care plan goals and objectives. When such
refusals are made, appropriate documentation will be entered into the residents clinical records in
accordance with established policies.
Based on record review, interview and policy review, the facility failed to initiate care plans for medication
use for two (Residents #18 and #22) of five residents reviewed for unnecessary medication. The facility
census was 45.
Findings include:
1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Her
diagnoses included suicidal ideations, major depressive disorder, anxiety disorder, bipolar disorder and
borderline personality disorder.
The quarterly Minimum Data Set (MDS) assessment, completed on 04/17/21, assessed the resident as
alert and oriented.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #18 was receiving Cymbalta Capsule Delayed Release Particles 20 milligrams (mg) to give two
capsules by mouth one time a day for depression, Lorazepam Tablet 0.5 mg to give one half tablet by
mouth every eight hours as needed for anxiety, and Seroquel, 100 mg to give 100 mg by mouth at bedtime
for bipolar depression.
Review of Resident #18's care plans revealed she did not have a care plan addressing psychoactive
medications.
During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) verified the
resident did not have a care plan addressing the psychoactive medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record
review for Resident #24 revealed an admission date of 06/12/07. The last quarterly MDS assessment was
dated 05/03/21.
Review of care conferences for Resident #24 revealed the last one was held on 11/11/20.
Interview with a family member on 06/28/21 at 3:02 P.M. revealed there hasn't been a care conference in
several months. The family member stated they do have care conference, but due to their work schedule,
they cannot attend. There have been no other arrangements made to attend a care conference.
During interview on 07/01/21 at 1:38 P.M., Social Worker Designee (SWD) #26 confirmed the last care
conference was on 11/20/20.
3. Record review for Resident #43 revealed an admission date of 01/18/21. The last quarterly MDS
assessment was dated 06/13/21.
Review of care conferences for Resident #43 revealed a care conference had never been held.
During interview on 06/28/21 at 11:42 A.M., Resident #43 stated no care conference had been held since
he admitted to the facility.
During interview on 07/01/21 at 1:38 P.M., SWD #26 confirmed no care conference had ever been held for
Resident #43.
Review of the facility policy titled Resident Participation-Assessment/Care Plans, dated 12/01/16, revealed
the resident and his or her representative are encouraged to participate in the resident's assessment and in
the development and implementation of the resident's care plan.
Based on record review and interview, the facility failed to ensure care conferences were held for residents.
This affected three (Residents #18, #24 and #43) of three residents reviewed for care planning. The facility
census was 45.
Findings include:
1. A review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. She had a
quarterly Minimum Data Set (MDS) assessment completed on 04/17/21.
There was no evidence a care conference had been held since admission.
During interview on 07/01/21 at 3:30 P.M., the Administrator and the Director of Nursing (DON) stated there
was no evidence that a care conference had been held for Resident #18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
record review for Resident #22 revealed she was admitted on [DATE].
Residents Affected - Few
Review of consultation report from the pharmacy issued on 03/02/21 and 05/05/21 revealed a request for
Lantus insulin 10 units in the morning and 25 units in the evening to be combined and given in the evening.
The recommendation was not reviewed, signed or dated by the physician.
During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) stated the
Assistant Director of Nursing (ADON) had the pharmacy recommendation records offsite and they would try
to get the information from the pharmacy.
At the time of exit, no policy on pharmacy recommendations and none of the information from the offsite
location or the pharmacy had been provided.
Based on record review and interview, the facility failed to ensure the physician documented review of
pharmacy recommendations. This affected three (Residents #18, #22 and #35) of five residents reviewed
for unnecessary medications. The facility census was 45.
Findings include:
1. Record review revealed Resident #18 was admitted to the facility on [DATE].
Pharmacy recommendations dated 04/06/21, 05/05/21, and 06/02/21 were not reviewed, signed or dated
by the physician.
2. Record review revealed Resident #35 was admitted to the facility on [DATE].
A review of the pharmacy recommendations dated 04/07/21, 04/19/21, and 05/17/21 were not reviewed,
signed or dated by the physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview and policy review the facility failed to prime insulin needles before
administration for one (#26) of one reviewed for insulin injections during the medication administration. The
facility identified six residents who received insulin pens. The census was 45.
Residents Affected - Few
Findings include:
Medical record review for Resident #26 revealed an admission date of 05/10/21. Medical diagnoses
included type two diabetes.
Review of physician orders dated 06/22/21 revealed Humalog KwikPen Solution Pen Injector to inject as
per sliding scale, to be given subcutaneously before meals and at bedtime for hyperglycemia.
During observation on 07/01/21 at 8:16 A.M., Registered Nurse (RN) #70 drew up four units on the
Humalog insulin pen. She did not dial up two units and did not expel the insulin to ensure the pen was
working properly. She stated she had primed the needle on the insulin pen when it was first opened and not
the beginning of each administration of the pen. She wasn't aware she was supposed to expel two units of
the insulin upon every use of the pen.
Review of the facility policy titled Medication Safety Alert/Insulin Pen Use, dated 01/01/14, revealed to turn
the dose selector to two units and hold the insulin pen with the needle pointing up and tap the cartridge
gently a few times to move air bubbles to the top. Press the push button all the way until the dose selector is
back to zero. A drop of insulin should appear at the tip of the needle. This must be done before each
injection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Knoll Post-Acute and Senior Living
4400 Vannest Avenue
Middletown, OH 45042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview and policy review, the facility failed to ensure a staff member donned
appropriate personal protective equipment when caring for a resident on quarantine. This affected one
(Resident #9) of three residents identified by the facility as being under quarantine. The facility census was
45.
Residents Affected - Few
Findings include:
Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE]. She was
discharged to the hospital on [DATE] and was readmitted on [DATE]. She had an order on 06/25/21 for strict
single room isolation with droplet precautions related to readmission from hospital regarding COVID
precautions every shift for 14 days.
During observation on 06/28/21 at 12:17 P.M., State Tested Nursing Assistant (STNA) #22 set up the
resident's lunch tray and sat on the side of the bed to assist the resident with eating. STNA #22 was
wearing a surgical mask, but no other personal protective equipment (PPE).
During interview on 06/28/21 at 12:20 P.M., Licensed Practical Nurse (LPN) #62 also observed STNA #22
sitting on the side of the resident's bed. She stated the only PPE STNA #22 was wearing was a surgical
mask. LPN #62 stated Resident #9 was on quarantine because of her recent hospital admission. LPN #62
stated anyone going into the room would have to wear full PPE, as if the resident had COVID.
A review of the facility's policy titled Infection Prevention and Control Program stated to implement
appropriate isolation precautions when necessary and follow established general and disease-specific
guidelines such as those of the Centers for Disease Control (CDC).
Review of the CDC Coronavirus Disease 2019 (COVID-19) fact sheet stated the preferred PPE included a
face shield or goggles, an N95 or higher respirator, an isolation gown and a pair of clean non-sterile gloves.
These are to be used when caring for a patient with confirmed or suspected COVID-19.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365648
If continuation sheet
Page 9 of 9
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Back to topCitations
27 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0753GeneralS&S Epotential for harm
Have restrictions on the use of highly flammable decorations.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F563 - The resident has a right to receive visitors of his or her choosing at the time o
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the July 9, 2021 survey of WILLOW KNOLL POST-ACUTE AND SENIOR LIVING?
This was a inspection survey of WILLOW KNOLL POST-ACUTE AND SENIOR LIVING on July 9, 2021. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WILLOW KNOLL POST-ACUTE AND SENIOR LIVING on July 9, 2021?
Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.