Willows of Presbyterian Senior

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen which created the potential for cross contamination. (Main Kitchen)

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for five of seven residents (Resident R38, R43, R44, R98, and R159), and failed to maintain the confidentiality of residents' medical information on one of nine medication carts (Third Floor West/Northwest Medication Cart).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the placement of a bed against the wall as a possible restraint, the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for three of three residents reviewed (Residents R6, R9, and R18).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Residents R7, R9, R10, R14 and R17).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for four of seven residents (Residents R16, R18, R47, and R80).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for three of seven residents (Residents R19, R77, and R137).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of five residents (Residents R1, R10, R98, R126, and R134).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for six of seven residents (Resident R43, R44, R57, R144, R150, and R159), and failed to maintain proper infection control practices related to the care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents (Resident R8).

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for two of seven residents (Resident R45 and R166).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R19).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order for a wound vac for one of one resident (Resident R189).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of three residents (Resident R6).

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R17).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (Fourth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of nine medication carts (Third Floor West/Northwest Medication Cart).

Inspectors wroteBased on review of facility policy, facility submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers, which resulted in actual harm of a head contusion (bruise) for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134), and failed to ensure that residents were free from neglect for an unknown skin condition injury for one of four residents reviewed (Resident R134).

Inspectors wroteFindings include: Review of facility policy Skilled Nursing - Lifting and Transferring Residents dated August 2025, indicated it is the policy to lift/transfer residents as safely as possible. All residents requiring assistance with transfer will be transferred and/or lifted using mechanical device unless otherwise indicated by a physician order, or unless the resident is able to bear weight on his/her own. Mechanical lifts are done by 2 nursing/therapy personnel. Review of the facility policy Unexplained Injuries dated August 2025, indicated an investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual to ensure that the safety of our residents has not been jeopardized. [...]

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8).

Inspectors wroteBased on a review of facility policies, documents and staff interviews it was determined that the facility failed to report to the State agency an allegation of misappropriation of resident property as required. (Allegation of misappropriation of resident property).

Inspectors wroteBased on review of facility policy and documents, clinical record, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella (knee) fracture, for one of two residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361).

Inspectors wroteBased on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of nine residents (Resident R46).

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Users Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of nine residents. (Resident 144)

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of two residents (Resident R36 and R158).

Inspectors wroteBased on facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for one of two residents (Resident R316) to accurately reflect the current status of the resident.

Inspectors wroteBased on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), and eating (Resident R60) for two of seven residents.

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure vital signs parameters (value ranges) were documented on the medication administration record per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care once healed for one of six residents (Resident R151).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R72).

Inspectors wroteBased on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of four residents reviewed (Resident R60).

Inspectors wroteBased on review of facility provided documents, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). Findings Include: Review of Title 42 Code of Federal Regulations §483.35(d) Requirement for facility hiring and use of nurse aides- §483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless- (i) That individual is competent to provide nursing and nursing related services; and (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 67).

Inspectors wroteBased on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of five residents observed during dining (Resident R60 and R74).

Inspectors wroteBased on facility policy, observations, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for two of five residents (Resident R74).

Inspectors wroteBased on review of clinical record review and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of five residents hospital transfers (Resident R77, R96, R131).

Inspectors wroteBased on review of facility policy, resident clinical record, facility incident documentation, resident and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per physician's order for one out of eight sampled resident records (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1).

Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to cover, label and date food products, properly dispose of contaminated food products, maintain the kitchen in a clean and sanitary manner, and properly wash and sanitize equipment in the Main Kitchen (Main Kitchen).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews it was determined that the facility failed to properly dispose of refuse to prevent the potential infestation of rodents and insects for three of three refuse disposal containers (recycle bin, furniture and equipment dumpster, and compactor unit).

Inspectors wroteBased on a review of facility employee personnel files, documents and staff interviews it was determined that the facility failed to employ a qualified Director of Dining Services (DDS) to manage the daily operations of the Dietary Department for 11 of 11 months. (1/23 through 11/23).

Inspectors wroteBased on review of facility policy, resident council group interview, resident and staff interview it was determined that the facility failed to offer residents the opportunity to vote for the November 2023 election (Second and Third floors).

Inspectors wroteBased on review of facility policy and records, and a staff interview, it was determined that the facility failed to notify a physician for a change in condition for one of four residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to protect residents from physical abuse for one of two residents reviewed (Resident R12).

Inspectors wroteBased on facility policy, review of facility submitted documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 12).

Inspectors wroteBased on review of clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R5).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for three of fourteen residents (Residents R5, R18, and R202).

Inspectors wroteBased on review of facility policy and records, and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for one of four residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policy and records, and a staff interview, it was determined that the facility failed to prevent pressure sore development and provide treatment as required for two of four residents (Resident R5 and R14). A review of the Dressing Change Policy policy dated 4/11/23, last reviewed 8/23, indicated it is the facility's policy to treat, measure, and track each wound individually. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. Section M: [...]

Inspectors wroteBased on review clinical records, and staff interviews it was determined that the facility failed to ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for two of six residents (Residents R5, R15, and R103), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of six residents (Resident R103).

Inspectors wroteBased on a review of clinical record, and staff interview, it was determined that the facility failed to ensure that proper hydration status was maintained by providing intravenous fluids as ordered for one of four residents (Resident R14).

Inspectors wroteBased on review of facility policy clinical record and resident and staff interview it was determined that the facility failed to provide medically related social services to one of seven residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policies, observations and staff interview, it was determined that the facility failed to ensure that outdated biologicals were discarded in one of two medication rooms (Second Floor), and to accurately date open medications for one of four medications carts (Second floor North-East medication cart).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of seven residents (Resident R5, R80, and R103).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to one of five residents (Resident R48).