Willow Springs Rehabilitation and Healthcare Cente

In the surveyor’s words

From the most serious findings on record at Willow Springs Rehabilitation and Healthcare Cente, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 12, 2024

  C/O # NJ163363 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to: a) assess a resident (Resident #534) in a timely manner by a Registered Nurse (RN) who had an unwitnessed fall which resulted in the resident experiencing pain and a right hip fracture. Resident #534 fell on [DATE] at approximately 6:00 PM, and was not assessed until the next day at approximately 10:15 AM (over 12 hours) by the Medical Doctor. […]

• No harm, potential for more than minimal, widespreadF812Jan 8, 2026

  Based on observation, interview and policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, and dishes were stacked dry. These failures had the potential to affect 153 residents who consumed food prepared by the kitchen.Findings include:Observations of the kitchen on 01/05/26 at 10:16 AM, revealed dust and debris were visible on the top of the dishwasher that included a rusted spring and dirty knife. The tile wall next to the grill had dust and stains scattered throughout the surface. The floor behind the oven and stove had a layer of black substance against the floorboard and under the three-compartment sink. The oven and stove top had built up grease and black debris. […]

• No harm, potential for more than minimal, widespreadF725Jul 12, 2024

  Complaint # NJ00168248, NJ00168274 Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the Facility Assessment revealed under the Staffing Guidelines that the facility created a staffing pattern to ensure their residents needs are met on a consistent basis. The assessment went on to indicate that Our facility staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. […]

• No harm, potential for more than minimal, patternF880Jan 8, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) when entering a room with a resident on transmission-based precautions, droplet precautions, and while providing direct care to a resident on enhanced barrier precautions (EBP) for two of five residents (Resident (R)40 and R89) reviewed for infection prevention and control out of a total sample of 49 residents. This failure placed staff and residents at risk of infection from cross-contamination.Findings include:.1. […]

• No harm, potential for more than minimal, patternF761Dec 20, 2022

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 4 of 4 medication carts on 2 of 2 (Cedar and Birch) nursing units reviewed for medication storage and was evidenced by the following: On 12/9/22 at 10:17 AM, while observing medication administration, the surveyor observed Licensed Practical Nurse (LPN #1) place a pre-filled insulin pen (injectable medication used to treat diabetes and lower blood sugar) with the needle still attached on Resident #70's tray table after administering the injection. […]