Willow Rehab & Nursing

In the surveyor’s words

From the most serious findings on record at Willow Rehab & Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF624Dec 12, 2024

  Based on record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 2 of 5 residents (Resident #1 and Resident #2) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/12/2024. Resident #1 was discharged from the facility with no place to go and made to sit outside and found approximately 7 hours later on the ground behind the facility and transported to the hospital with A-fib and high blood pressure. The facility failed to ensure Resident #2 had a safe and orderly discharge to a home environment on 11/14/2024. […]

• Immediate jeopardy, isolatedF695Jun 13, 2025

  Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, is provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that CNA B effectively communicated to RN A that Resident #1 requested a nurse. The facility failed to ensure that CNA B recognized a change of condition in Resident #1 that needed to be emergently communicated to RN A. The facility failed to ensure CNA C reported Resident #1's change of condition to RN A. […]

• Immediate jeopardy, isolatedF689Dec 12, 2024

  Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #3) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #3 elopement on 9/20/2024. Resident #3, who had dementia, left the facility through an alarmed door on 9/20/2024 at 5:05 PM. The resident wandered approximately 200 yards down the road from the facility driveway and was intercepted by Medical Records and returned to the facility. An IJ was identified on 12/11/2024. The IJ template was provided to the facility on [DATE] at 1:55 PM. […]

• Immediate jeopardy, isolatedF600Aug 30, 2022

  Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents reviewed (Resident #1) for neglect. 1. The facility failed to follow their Fall Management System policy. 2. The facility failed to ensure interventions were in place for Resident #1 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. The facility failed to ensure neurological checks were completed when Resident #1 had an unwitnessed fall. The LVN documented neurological checks were completed; however, video reviewed by the police indicated the LVN did not enter the resident's room for 3 hours and 50 minutes after the fall when the resident had another fall. 4. […]

• Actual harm, isolatedF697Oct 21, 2022

  Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 21 residents reviewed for pain management. (Resident #24) The facility failed to reorder Resident #24's [MEDICATION(S)] timely therefore leaving her without the pain medication for 7 days. The facility failed to adequately assess Resident #24's pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. […]