WILLOW HAVEN

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Oklahoma are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/30/2011.

Administration

Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Keep Accurate and Appropriate Medical Records. Inspection Date: 11/14/2008 Correction Date: 12/19/2008
Be Administered in a Way That Leads to the Highest Possible Level of Well Being for Each Resident. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Get Proof That a Nurse Aide Has the Training and Skills That the State Requires. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Keep Accurate and Appropriate Medical Records. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Set Up or Keep a Group of People to Review and Ensure Quality. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Environmental

Provide Needed Housekeeping and Maintenance. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 11/14/2008 Correction Date: 12/05/2008
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Provide Clean Bed and Bath Linens That Are in Good Condition. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 03/30/2011 Correction Date: 06/03/2011
Have a Program to Keep Infection from Spreading. Inspection Date: 03/30/2011 Correction Date: 05/04/2011
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 03/30/2011 Correction Date: 05/04/2011
Put Firmly Secured Handrails on Each Side of Hallways. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Mistreatment

Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 11/14/2008 Correction Date: 02/20/2009
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Nutrition and Dietary

1) Provide 3 Meals Daily at Regular Times; or 2) Serve Breakfast Within 14 Hours After Dinner; or 3) Offer a Snack at Bedtime Each Day. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 01/07/2010 Correction Date: 03/22/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 03/30/2011 Correction Date: 05/04/2011
Properly Mark Drugs and Other Similar Products. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Quality Care

Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 11/14/2008 Correction Date: 12/15/2008
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 11/14/2008 Correction Date: 12/05/2008
Use a Registered Nurse at Least 8 Hours a Day, 7 Days a Week. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Provide Activities to Meet the Needs of Each Resident. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 03/30/2011 Correction Date: 05/04/2011
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Resident Assessment

Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 11/14/2008 Correction Date: 02/20/2009
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 11/14/2008 Correction Date: 02/20/2009
Electronically Record and Report Resident Status Assessments in a Timely Manner As Required in Order to Monitor Resident Health and Progress. Inspection Date: 11/14/2008 Correction Date: 01/10/2009
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 11/14/2008 Correction Date: 12/08/2008
Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Check and Update (If Needed) Each Resident's Assessment Every 3 Months. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 03/30/2011 Correction Date: 05/04/2011
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 11/14/2008 Correction Date: 12/05/2008
Send and Promptly Deliver Unopened Mail to Residents. Inspection Date: 11/14/2008 Correction Date: 12/06/2008
Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care. Inspection Date: 01/07/2010 Correction Date: 01/28/2010
Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 03/30/2011 Correction Date: 05/04/2011

The table below lists incident reports by the nursing staff or administration for Willow Haven, as well as complaints by residents or their family in the previous three years.

Administration

Be Administered in a Way That Leads to the Highest Possible Level of Well Being for Each Resident. Complaint Filed: 09/13/2010 Correction Date: 09/27/2010
Set Up or Keep a Group of People to Review and Ensure Quality. Complaint Filed: 09/13/2010 Correction Date: 09/30/2010

Environmental

Have a Program to Keep Infection from Spreading. Complaint Filed: 01/07/2010 Correction Date: 01/28/2010
Provide Needed Housekeeping and Maintenance. Complaint Filed: 01/07/2010 Correction Date: 03/22/2010

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Complaint Filed: 07/16/2009 Correction Date: 08/20/2009
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Complaint Filed: 09/13/2010 Correction Date: 10/05/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Complaint Filed: 09/13/2010 Correction Date: 10/05/2010

Nutrition and Dietary

Make Sure That Residents Are Well Nourished. Complaint Filed: 01/07/2010 Correction Date: 01/28/2010
Make Sure That the Attending Doctor Orders Special Diets. Complaint Filed: 01/07/2010 Correction Date: 01/28/2010
Make Sure That Residents Are Well Nourished. Complaint Filed: 09/13/2010 Correction Date: 12/02/2010

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Complaint Filed: 09/21/2009 Correction Date: 09/22/2009

Quality Care

Use a Registered Nurse at Least 8 Hours a Day, 7 Days a Week. Complaint Filed: 09/13/2010 Correction Date: 09/21/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Willow Haven had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 03/31/2011.

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 03/31/2011 Correction Date: 05/04/2011

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 03/31/2011 Correction Date: 05/04/2011

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 01/05/2010 Correction Date: 01/08/2010

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 11/13/2008 Correction Date: 01/10/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 01/05/2010 Correction Date: 01/28/2010
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 03/31/2011 Correction Date: 05/04/2011
Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 03/31/2011 Correction Date: 05/04/2011

Illumination and Emergency Power

Proper Backup Exit Lighting. Inspection Date: 01/05/2010 Correction Date: 01/28/2010
Emergency Lighting That Can Last at Least 1 1/2 Hours. Inspection Date: 03/31/2011 Correction Date: 05/04/2011

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 01/05/2010 Correction Date: 01/08/2010