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 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-10-04 | Y |
