Willowbend Health and Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Willowbend Health and Rehabilitation, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 6, 2025

  Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #25) of 4 sampled residents reviewed for neglect received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure 2 staff members transferred Resident #25 using the appropriate lift based on Resident #25's needs and care plan which resulted in Resident #25 sustaining a dislocated right shoulder. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, isolatedF684Mar 28, 2024

  Based on record review and interview, the facility failed to fully assess a resident experiencing respiratory distress in a timely manner, failed to follow physician's order during an acute incident which resulted in a change of condition, and failed to notify the physician of the change in condition in a timely manner for 1 (Resident #368) of 3 sampled residents reviewed for a change in condition. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2026

  Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to store and serve food in accordance with professional standards for food safety services for three (Resident #43, #38 and #109) of 19 residents reviewed. Specifically, meats were not served at the acceptable temperature of 135 degrees, food was not appropriately sealed and stored in the freezer, there were expired foods stored in the dry food storge area, and prepared liquids were not dated and sealed when stored in the refrigerator. The findings include: During an observation on 08/02/2026 at 10:05 AM, three items were observed in the freezer open and unsealed. […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2021

  Based on observation and interview, the facility failed to ensure seasoning stored in a dry area was covered; failed to ensure leftover food items were used by its use-by date to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods stored in the freezer and refrigerator were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure refrigerator temperature was maintained at 41 degrees Fahrenheit or below and cold drinks in the refrigerator were maintained at 41 degrees Fahrenheit or below to prevent potential for bacteria growth for the residents who received meals from 1 of 1 kitchen; staff washed their hands before handling clean equipment or food items… […]

• No harm, potential for more than minimal, patternF759Aug 5, 2026

  Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was less than five percent during a medication administration observation of one (Residents #86) of five residents. This surveyor observed 26 opportunities for medication administration, with 2 of the 26 medications not being administered in accordance with the Physician's Orders, resulting in a medication error rate of 7.6 percent. The findings include: Resident #86 During a medication administration observation on 08/04/2026 at 8:00 AM, the Registered Nurse (RN) #2 prepared Resident #86's medications. […]