Deficiency Records for Willows of Presbyterian Senior
Updated as of May 01, 2019
This is not the most recent data for Willows of Presbyterian Senior. For the most recent information, click here.
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 safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-01 | 2019-01-02 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-02 | 2018-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-05 | 2018-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-05 | 2018-11-12 | 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 | 2018-10-05 | 2018-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-05 | 2018-11-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-05 | 2018-11-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-05 | 2018-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-05 | 2018-11-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-05 | 2018-11-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-11-07 | 2018-01-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-11-07 | 2018-01-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-11-07 | 2018-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-07 | 2018-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-07 | 2018-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-03 | 2017-12-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-11-03 | 2017-12-27 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-03 | 2017-12-27 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-05-19 | 2017-06-21 | Y |
| Provide written records when a resident is transferred or discharged. | Health | 2016-10-21 | 2016-11-28 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-10-21 | 2016-11-28 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-10-21 | 2016-11-28 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-10-21 | 2016-11-28 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-10-21 | 2016-11-28 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-10-18 | 2016-11-17 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-10-18 | 2016-11-17 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-18 | 2016-11-17 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-10-18 | 2016-11-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-05-18 | 2016-06-21 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-05-18 | 2016-06-21 | Y |
