Willow Dale Wellness Village

In the surveyor’s words

From the most serious findings on record at Willow Dale Wellness Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Jun 13, 2022

  Based on resident interviews, clnical record reviews, and staff interviews, the facility failed to provide Care Conferences or have each member of the Interdisciplinary Team (IDT) review the Care Plan with the resident for five (Residents #4, #12, #14, #19, and #28) of sixteen residents reviewed. The facility reported a census of 32 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 6/6/22 at 2:11 PM, Resident #4 stated she didn't know of any care conferences. She reported that she didn't attend a Care Conference or get invited to one. […]

• No harm, potential for more than minimal, isolatedF657Dec 11, 2025

  Based on clinical record review, staff interview, guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and facility policy review, the facility failed to update the Comprehensive Care Plan for 1 of 13 residents (Resident #32) reviewed for Care Planning. The facility reported a census of 29 residents. Findings include:The Annual Minimum Data Set (MDS) of Resident #32, dated 8/31/25, documented diagnoses that included atrial fibrillation, heart failure and hypertension. […]

• No harm, potential for more than minimal, isolatedF759Dec 11, 2025

  Based on observation, staff interview, clinical record review, drug manufacturer guidance, and facility policy review, the facility failed to assure a medication error rate of less than 5%. Medication administration was observed for a total of five residents, with errors being observed for one of five residents (Resident #25). A total of 26 ordered medications were reviewed with two errors, an error rate of 7.7%. The facility reported a census of 29 residents. Findings include:On 12/10/25 at 7:48 am, the observation of the medication pass began. Staff A, Licensed Practical Nurse (LPN) stated Resident #25 was done eating his breakfast so she would start with him. Staff A prepared a total of 12 medications for Resident #25. […]

• No harm, potential for more than minimal, isolatedF656Nov 14, 2024

  Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 3 out of 12 sampled residents reviewed for comprehensive care plans (Resident #20, #21 and #22). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of cancer, hypertension and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately cognitive impairment. The MDS revealed the resident was taking diuretic medication in the review period. […]

• No harm, potential for more than minimal, isolatedF644Aug 24, 2023

  Based on clinical record review and staff interview, the facility failed to refer two residents with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 3 residents (Residents #6 and #7) reviewed for PASRR requirements. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnosis of dementia, depression, and anxiety disorder. The MDS included diagnoses of anxiety disorder and depression. […]