Willow Haven Health and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Willow Haven Health and Rehab, LLC, in the surveyor’s own words.

• Actual harm, isolatedF627Mar 24, 2026

  Based on observation, interview, record review, and document review, the facility failed to ensure:1) a resident was readmitted to the facility following hospitalization for 1 of 8 sampled residents (R1), and2) written criteria addressing residents hospitalized under a legal hold (L2K) was formulated and implemented. The deficient practice resulted in R1, who required medication management, assistance with activities of daily living, and nursing supervision, being left without housing, care, and access to prescribed medications, placing the resident at risk for serious harm, including deterioration in condition, hospitalization, or death.The deficient practice had the potential to affect other residents in the facility who required similar services if the practice continued.Findings… […]

• Actual harm, isolatedF689Dec 11, 2025

  Based on observation, interview, record review and document review the facility failed to ensure 1) staff re-assessed the smoking status and updated the care plan after a significant change of condition was completed regarding a decline in cognition and accurately assess the tobacco use section of the Minimum Data Set (MDS); 2) complete a safe smoking assessment and update the plan of care for a resident was found smoking inside room; and 3) ensure a resident lighter and cigarettes were secured for 1 of 38 sampled residents (Resident 1). […]

• Actual harm, isolatedF658Mar 31, 2023

  Based on interview and record review, the facility failed to ensure professional standards were followed for a choking resident by administering emergency first aid such as abdominal thrust, for 1 of 8 sampled residents (Resident #1). The deficient practice resulted in the resident being unable to expel the foreign object from their airway. Resident #1 (R1) R1 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen). R1's history and physical dated [DATE], documented R1 had history of CVA with aphasia and dysphagia. […]

• Actual harm, isolatedF684Mar 31, 2023

  Based on interview and record review, the facility failed to ensure emergency medical services were activated to transport a choking resident to an acute care facility when staff were unable to clear the foreign body obstructing the airway, for 1 of 8 sampled residents (Resident #1). The deficient practices resulted in the deprivation of emergency procedures to clear the resident's airway. Findings include: Resident #1 (R1) R1 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen). […]

• No harm, potential for more than minimal, widespreadF921Dec 11, 2025

  Based on observation, interview and document review, the facility failed to ensure the fire alarm system, portable fire extinguishers and fire safety plan were maintained in accordance with the following National Fire Protection Association (NFPA) standards:NFPA 72 National Fire Alarm and Signaling Code, the 10 Standard for Portable Fire Extinguishers, and the 101 Life Safety Code. The deficient practice affected 36 residents in one of six smoke compartments. The facility was licensed for 144 nursing beds with a census of 137 the day of survey. Findings include: 1) On 12/11/2025, during a tour of the facility, the main fire alarm panel displayed a system trouble alarm. The panel display indicated MISSING DUCT DECTECTOR H20 HEATER ROOM. […]