Willow Valley Center for Nursing and Rehabilitatio

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Aug 29, 2025

  Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a blood glucose meter (glucometer) assigned to Resident #11 and used a glucometer that was assigned to another resident, Resident #141, to check Resident #11's blood glucose level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #11's blood glucose level and would have had no way to know if another staff member had previously disinfected the glucometer assigned to another resident. Glucometers can become contaminated with blood and must be disinfected after each use with an approved product and procedure. […]

• Immediate jeopardy, isolatedF580Aug 7, 2023

  Based on record review, staff, and Nurse Practitioner (NP) interviews the facility failed to immediately notify the physician of Resident #250's unwitnessed fall that occurred on [DATE] at 1:00 p.m. The on-call physician was not notified of the fall until [DATE] at 6:50 p.m. when it was discovered the resident had an altered mental status. The facility also failed to immediately notify the physician when the ordered intervention of STAT (immediate) laboratory work and normal saline (mixture of sodium chloride and water used to treat dehydration) were not able to be completed STAT. Additionally, the facility failed to notify the physician of Resident #250's tube feeding that was found leaking on the floor and in the bed. […]

• Immediate jeopardy, isolatedF684Aug 7, 2023

  Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews the facility failed to ensure a resident had on-going comprehensive assessments completed after a resident with functional quadriplegia experienced a second unwitnessed fall on [DATE] at 1:00 p.m. and then later that same day had altered mental status due to suspected dehydration. A Physician video visit was conducted on [DATE] at 6:50 p.m. to evaluate the resident due to altered mental status. At that time the physician noted the resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. […]

• Immediate jeopardy, isolatedF692Aug 7, 2023

  Based on record review and staff, Registered Dietician (RD), Speech Therapy (SLP), Nurse Practitioner (NP) and Physician interviews, the facility failed to maintain the hydration status for 1 of 2 residents reviewed for tube feedings (Resident # 250). When it was determined the resident was dehydrated, the facility failed to administer ordered fluids immediately, and failed to complete STAT (immediate) laboratory orders to assess the resident and provide information to the physician for needed treatment. […]

• Immediate jeopardy, isolatedF580May 24, 2022

  Based on record review, staff, Medical Director (MD) and Nurse Practitioner (NP) interviews, the facility failed to: 1) immediately inform the physician when Resident #610 had an unwitnessed fall and could not get up as usual and notify the physician of x-ray results upon receipt from the radiology company. Resident #610 was diagnosed with a fractured femur and a spinal injury. 2) notify the physician after a Resident #607, who received anticoagulant medication, fell for two of three residents reviewed for accidents (Residents #610 and #607). Immediate Jeopardy began on 5/2/2022 when the facility failed to inform the physician that Resident #610 had an unwitnessed fall and could not get up on his own, as usual. […]