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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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-11-22 | 2025-01-02 | N |
| 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. | Health | 2024-11-22 | 2025-01-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-11-22 | 2025-01-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-11-22 | 2025-01-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-11-22 | 2025-01-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-11-22 | 2025-01-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-11-22 | 2025-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-22 | 2025-01-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-22 | 2025-01-02 | N |
| 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. | Health | 2024-11-22 | 2025-01-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-11-22 | 2025-01-02 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-11-22 | 2025-01-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-11-22 | 2025-01-02 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-11-22 | 2025-01-02 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-11-22 | 2025-01-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-11-25 | 2025-01-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-11-25 | 2025-01-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-11-25 | 2025-01-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-11-25 | 2025-01-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-11-25 | 2025-01-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-09 | 2024-07-03 | Y |
| 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 |
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