Deficiency Records for Willows of Presbyterian Senior
Updated as of May 01, 2022
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? |
|---|---|---|---|---|
| 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 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-27 | 2019-11-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-27 | 2019-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-27 | 2019-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-27 | 2019-11-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-27 | 2019-11-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-26 | 2019-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-05-21 | 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 |
