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Deficiency Records for Willows of Presbyterian Senior

A list of the most recent deficiencies for Willows of Presbyterian Senior. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Willows of Presbyterian Senior. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2024-03-20 2024-04-22 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-03-20 2024-04-22 Y
Provide properly protected cooking facilities. Fire Safety 2023-11-14 2024-01-11 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-14 2024-01-11 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-11-14 2024-01-11 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-11-14 2024-01-11 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-11-14 2024-01-11 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-14 2024-01-11 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-11-20 2024-01-01 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-11-20 2024-01-01 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-11-20 2024-01-01 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-20 2024-01-01 N
Assess the resident when there is a significant change in condition Health 2023-11-20 2024-01-01 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-20 2024-01-01 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-20 2024-01-01 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-11-20 2024-01-01 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2023-11-20 2024-01-01 N
Provide enough food/fluids to maintain a resident's health. Health 2023-11-20 2024-01-01 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2023-11-20 2024-01-01 N
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. Health 2023-11-20 2024-01-01 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2023-11-20 2024-01-01 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-20 2024-01-01 N
Dispose of garbage and refuse properly. Health 2023-11-20 2024-01-01 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2023-11-20 2024-01-01 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-11-20 2024-01-01 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-02-15 2023-03-20 Y
Have properly located and lighted "Exit" signs. Fire Safety 2022-12-22 2023-02-14 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-12-22 2023-02-14 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-22 2023-02-14 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-12-22 2023-02-14 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-12-22 2023-02-14 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-12-16 2023-02-01 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2022-12-16 2023-02-01 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-12-16 2023-02-01 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-16 2023-02-01 N
Provide activities to meet all resident's needs. Health 2022-12-16 2023-02-01 N
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. Health 2022-12-16 2023-02-01 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-12-16 2023-02-01 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-12-16 2023-02-01 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-16 2023-02-01 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2021-12-03 2022-01-17 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-12-03 2022-01-17 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2021-12-03 2022-01-17 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-03 2022-01-17 N
Provide enough food/fluids to maintain a resident's health. Health 2021-12-03 2022-01-17 N
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. Health 2021-12-03 2022-01-17 N
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. Fire Safety 2021-12-01 2022-01-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-12-01 2022-01-17 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-12-01 2022-01-17 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-12-01 2022-01-17 N
Have power receptacles that are properly grounded. Fire Safety 2021-12-01 2022-01-17 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-12-01 2022-01-17 N

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