Willows of Presbyterian Senior

In the surveyor’s words

From the most serious findings on record at Willows of Presbyterian Senior, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 23, 2025

  Based 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. Findings include: Review of the facility policy Elopement Process dated August 2024, indicated an elopement assessment is completed upon admission, quarterly, annually, and if a resident actively attempts to elope. […]

• Actual harm, patternF600Oct 15, 2025

  Based 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).Findings include:Review of facility policy Skilled Nursing - Abuse dated August 2025, indicated neglect is defined as the failure of the community, its employees or services providers to provide goods… […]

• Actual harm, patternF689Oct 15, 2025

  Findings 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.Review of the facility policy… […]

• Actual harm, isolatedF689May 8, 2025

  Based 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). Findings include: Review of facility policy, Skilled Nursing - Investigation of incidents update August 2024, indicated the purpose is to establish guidelines for investigations of incidents and accidents to determine the root cause of the event and to identify systemic changes and measures needed to prevent future incidents. The facility will conduct a thorough and timely investigation of incidents and accidents. […]

• No harm, potential for more than minimal, widespreadF812Dec 2, 2025

  Based 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)Findings include: During an observation on 9/22/25, at 9:30 a.m. it was revealed the ice machines in the main kitchen contained a brown substance inside the machine. During an interview on 9/22/25, at 9:50 am the Dietary Director E8 confirmed the brown substance in the ice machine and could not verify the last time it was sanitized creating the potential for cross contamination. 28 Pa Code: 201.14(a) Responsibility of licensee.