Willow Point Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Willow Point Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF883Mar 29, 2024

  Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024, the facility failed to vaccinate eligible residents with the pneumococcal vaccination (a vaccination developed to minimize the risk of acquiring, transmitting, or experiencing complications of pneumonia) for 44 of 245 residents who consented to the pneumococcal vaccine. Specifically, from 9/5/2023 through 3/25/2024, Residents #12, #14, #17, #18, #24, #27, #31, #43, #45, #57, #63, #74, #82, #95, #102, #103, #108, #109, #117, #118, #126, #129, #134, #165, #173, #177, #186, #192, #213, #214, #215, #216, #219, #222, #224, #226, #229, #235, #484, #533, #585, #586, #587, and #633 consented to and had medical orders to receive the pneumococcal vaccine and did not receive it. […]

• Actual harm, patternF689Mar 29, 2024

  Based on observation, record review and interview during the recertification and abbreviated (NY00314754, NY00319010, NY00320020, NY00327419, NY00331182, and NY00334923) surveys conducted 3/18/2024-3/29/2024 the facility failed to provide adequate supervision to prevent accidents for 4 of 10 residents (Residents #114, #174, #191, and #213) reviewed. Specifically, Residents #114, #191, and #213 were subjected to physical aggression and sexually abusive behaviors by Resident #174 and the facility failed to develop or implement strategic interventions for Resident #174 to protect other residents from victimization. […]

• Actual harm, isolatedF760Jan 27, 2023

  Based on record review and interview during the abbreviated survey (NY00308336), the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was not administered their anticoagulation (prevents blood from clotting) medication (Eliquis) for 29 days and subsequently developed a pulmonary embolism (PE, a blood clot that travels to the lungs where it blocks blood flow). This resulted in actual harm to Resident #1 that was not immediate jeopardy. […]

• No harm, potential for more than minimal, widespreadF726Mar 29, 2024

  Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024, the facility did not ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well- being for each resident for 4 of 4 licensed nurses (licensed practical nurses #31, #45, #48, and registered nurse #51) reviewed. Specifically, licensed practical nurses #31, #45, #48 and registered nurse #51 did not receive routine competency evaluations that covered key skill-set areas including accessing venous access devices, vacuum assisted wound closure devices (wound VACs), hand hygiene, and medication administration. […]

• No harm, potential for more than minimal, widespreadF730Mar 29, 2024

  Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024 the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 5 of 5 certified nurse aides (certified nurse aides #35, #41, #42, #43, and #44) reviewed. Specifically, there was no documented evidence certified nurse aides #35, #41, #42, #43, and #44 had performance reviews at least once every 12 months. Findings include: The facility policy titled Staff Evaluations, last modified 11/9/2018, documented the facility would provide ongoing feedback to all staff members regarding their performance at specific intervals to encourage continuous improvement as needed. All staff members would receive an annual performance evaluation. […]