Willowdale Village

In the surveyor’s words

From the most serious findings on record at Willowdale Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF727Dec 16, 2024

  Based on interview and record review, the facility failed to ensure services of a Registered Nurse (RN) were available at least 8 consecutive hours in a 24 hour period, 7 days a week for 2 of 7 days reviewed for nurse staffing. (11/29/24, 11/30/24) Findings include: On 12/11/24 at 9:50 A.M., the daily nursing schedules were provided for the week of 11/27/24 through 12/3/24 and reviewed. The schedules indicated there was an RN that worked from 6:00 P.M. to midnight (6 consecutive hours) on Friday, 11/29/24 and lacked RN coverage on Saturday, 11/30/24. During an interview on 12/16/24 at 12:10 P.M., the Director of Nursing (DON) indicated there was not RN coverage for those dates but there should have been 8 hours of consecutive RN coverage every day. […]

• No harm, potential for more than minimal, patternF657Dec 21, 2023

  Based on interview and record review, the facility failed to insure care plan conferences were completed quarterly for 4 of 10 residents reviewed for care plans. (Resident 2, Resident 3, Resident 15, Resident 22) Findings include: 1. On 12/20/23 at 9:22 A.M., Resident 3's clinical record was reviewed. Resident 3 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dysphagia. The most recent quarterly MDS (minimum data set) Assessment was completed on 9/20/23. Resident 3's cognitive level was moderately impaired, and required extensive assistance for mobility and eating, and total dependence for toileting and bathing. Care plan conferences during the past 12 months were held on 3/3/23, 3/31/23, and 7/5/23. 2. […]

• No harm, potential for more than minimal, isolatedF580Feb 13, 2026

  Based on interview and record review, the facility failed to ensure physician notification for a resident's change of condition for 1 of 5 residents reviewed for unnecessary medications. A resident's physician was not notified following insulin being held due to low blood sugar. (Resident 5)Findings include:On 2/11/26 at 11:08 A.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated a moderate cognitive impairment, and use of insulin. Physician orders included, but were not limited to: insulin aspart U-100 solution; 100 unit/mL (milliliters); amount to administer: 6 units, dated 7/15/25 through 1/16/26. […]

• No harm, potential for more than minimal, isolatedF880Dec 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 1 of 1 residents reviewed for Transmission Based Precautions (TBP). Staff failed to don (put on) personal protective equipment (PPE) prior to entering a contact isolation room. (Resident 16) Findings include: During an observation on 12/11/24 at 8:45 A.M., the following sign was observed on Resident 16's door, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands (hand sanitizer or hand washing) before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. […]

• No harm, potential for more than minimal, isolatedF761Dec 21, 2023

  Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 1 of 2 medication carts. The narcotic box was not locked in the medication cart. (West Hall) Finding includes: On 12/20/23 at 7:23 A.M., the narcotic box in the [NAME] Hall Medication Cart was observed unlocked. On 12/20/23 at 9:56 A.M., the narcotic box in the [NAME] Hall Medication Cart was observed unlocked. During an interview on 12/20/23 at 10:00 A.M., Registered Nurse (RN) 20 indicated the narcotic box should be locked. During an interview on 12/20/23 at 10:10 A.M., RN 35 indicated narcotic boxes in the medication cart should be locked anytime the nurse was not in it. […]