Inspection Reports for
The Willows at Ramapo Rehabilitation and Nursing Center
NY, 10901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Oct 24, 2025
Visit Reason
The abbreviated survey was conducted to investigate care and treatment deficiencies related to Resident #1, including failure to provide appropriate assistance with activities of daily living and accurate medical record documentation.
Findings
The facility failed to provide Resident #1 with necessary care during the evening shift on 10/06/2025, resulting in the resident falling and sustaining injuries that led to death. Additionally, inaccurate documentation was found where care was documented as provided but was not delivered, and hourly rounding was documented after the resident's death.
Deficiencies (2)
F 0684: The facility failed to ensure residents receive treatment and care according to professional standards and the person-centered care plan. Certified Nurse Aide #1 did not provide Resident #1 with required assistance during the evening shift on 10/06/2025, leading to Resident #1 falling and sustaining injuries resulting in death.
F 0842: The facility did not maintain accurate medical records for Resident #1. Certified Nurse Aide #1 documented care that was not provided, and Licensed Practical Nurse #10 documented hourly rounding after Resident #1 had expired and was removed from the facility.
Report Facts
Residents reviewed: 3
Residents affected: 1
Date of incident: Oct 6, 2025
Time of death: 1220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in failure to provide care and inaccurate documentation for Resident #1 | |
| Licensed Practical Nurse #3 | Noted Resident #1 was not changed and did not follow up on care | |
| Licensed Practical Nurse #10 | Documented hourly rounding after Resident #1's death | |
| Registered Nurse Supervisor #1 | Responded to Resident #1 fall incident | |
| Director of Nursing | Prepared incident report and interviewed staff regarding care failures | |
| Medical Director | Reviewed medical records and incident findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding infection prevention and control practices at the facility.
Complaint Details
The complaint investigation (NY00374056) found that staff failed to wear gowns when providing care to Resident #2 who was on enhanced barrier precautions. Interviews revealed some staff were unaware or forgot to wear gowns. The facility had policies and training in place but compliance was lacking.
Findings
The facility failed to maintain infection prevention and control practices for one resident on enhanced barrier precautions. Staff were observed providing hands-on care without wearing gowns as required by the facility's policy.
Deficiencies (1)
F 0880: The facility did not provide and implement an infection prevention and control program in accordance with enhanced barrier precautions. Staff were observed providing care to Resident #2 without wearing gowns on multiple occasions.
Report Facts
Residents Affected: 1
Training dates: 2024
Training dates: 2025
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
One isolated Level 2 deficiency related to care plan timing and revision was identified and corrected.
Findings
One isolated Level 2 deficiency related to care plan timing and revision was identified and corrected.
Deficiencies (1)
Care plan timing and revision
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The abbreviated survey was conducted to review compliance with care plan requirements, specifically focusing on the timely review and revision of the Comprehensive Care Plans for residents.
Findings
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for Resident #2, resulting in the Certified Nurse Aide being unaware of the required two-person assist for care. This led to an incident where care was provided without the required assistance, triggering an accusation of abuse.
Deficiencies (1)
F 0657: The facility did not develop, review, and revise the complete care plan within 7 days of the comprehensive assessment as required. Resident #2's Behavior Care Plan was not updated to reflect the two-person assist requirement in the Certified Nurse Aide documentation prior to an incident on 1/7/24.
Report Facts
Residents reviewed for Abuse: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in relation to providing care without required two-person assist | |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Provided information about care plan initiation, review, and revision responsibilities |
| Director of Nursing | Director of Nursing | Provided information about care plan responsibilities and acknowledged failure to activate certified nurse aide tasks |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
Multiple Level 2 deficiencies related to activities, food sanitation, mobility, investigation of violations, quality of care, resident rights, and respiratory care were identified and corrected.
Findings
Multiple Level 2 deficiencies related to activities, food sanitation, mobility, investigation of violations, quality of care, resident rights, and respiratory care were identified and corrected.
Deficiencies (7)
Activities meet interest/needs each resident
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Investigate/prevent/correct alleged violation
Quality of care
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to conduct a thorough investigation of alleged abuse and neglect, inadequate provision of activities, medication administration errors, failure to provide appropriate treatment for range of motion, improper respiratory care, and unsafe food storage and handling practices.
Deficiencies (6)
F 0610: The facility did not ensure a thorough investigation for Resident #70 regarding missed administration of Magnesium Citrate and alleged abuse. The medication was not administered timely, and the physician and pharmacy were not notified.
F 0679: Resident #39 was not provided ongoing activities or opportunities to participate in independent activities of their choice, and there was no evidence of reassessment of preferences.
F 0684: Resident #70 did not receive timely medication for constipation, and Resident #63 was not given medication with meals as ordered, failing to meet professional standards of care.
F 0688: Resident #120 was not provided soft booties as recommended by physical therapy to maintain range of motion and prevent contractures, with no physician order or care plan documentation directing their use.
F 0695: Resident #82 did not receive continuous oxygen therapy as ordered; observations showed the nasal cannula was frequently not in use despite physician orders.
F 0812: Food service deficiencies included unsanitary refrigeration units, unlabeled defrosted ground beef, missing cooling logs, nourishment refrigerators not maintained at safe temperatures, and improper food handling practices by staff.
Report Facts
Date survey completed: Nov 17, 2023
Medication doses missed: 2
Temperature readings: 51.4
Temperature readings: 48.7
Temperature readings: 48.2
Temperature readings: 46
Temperature readings: 45
Temperature readings: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in investigation of alleged abuse and medication omission for Resident #70 |
| LPN #2 | Licensed Practical Nurse | Responsible for medication administration to Resident #70 and involved in medication omission |
| LPN #3 | Licensed Practical Nurse | Responsible for evening medication administration for Resident #70 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication omission and investigation procedures |
| Physician #1 | Primary Care Physician | Interviewed regarding Resident #70's disimpaction and medication administration |
| Director of Activities | Director of Activities | Interviewed regarding Resident #39's activity participation and documentation |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Observed and interviewed regarding medication administration for Resident #63 |
| LPN #6 | Licensed Practical Nurse | Medication nurse for Resident #63, interviewed about medication administration with meals |
| Medical Director | Medical Director | Interviewed regarding medication administration standards |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding Resident #120's physical therapy and use of soft booties |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen therapy procedures for Resident #82 |
| Cook #1 | Cook | Observed and interviewed regarding food handling and temperature monitoring practices |
| Food Service Director | Food Service Director | Interviewed regarding food storage, sanitation, and cooling logs |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 17, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 11/8/2023 through 11/17/2023 to assess compliance with regulatory standards for The Willows at Ramapo Rehab and Nursing Center.
Findings
The facility was found deficient in ensuring residents' rights to dignified care during dining, conducting thorough investigations of alleged abuse and neglect, and providing timely and appropriate medication administration according to physician orders.
Deficiencies (3)
F 0550: The facility failed to ensure a dignified dining experience for 3 residents who were observed eating in the hallway without social interaction or preference accommodation.
F 0610: The facility did not conduct a thorough investigation for 1 resident regarding missed administration of magnesium citrate, which led to manual dis-impaction without prior notification to the physician or pharmacy.
F 0684: The facility failed to provide timely medication for constipation to 1 resident and did not administer a prescribed medication with meals to another resident as ordered.
Report Facts
Residents reviewed for dignity: 3
Residents reviewed for abuse/neglect: 3
Residents reviewed for medications: 3
Magnesium Citrate doses ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in investigation of alleged abuse and manual dis-impaction of Resident #70 |
| LPN #2 | Licensed Practical Nurse | Responsible for medication administration to Resident #70 and involved in investigation |
| LPN #3 | Licensed Practical Nurse | Responsible for evening medication administration for Resident #70 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and investigation |
| Physician #1 | Physician | Primary care physician for Resident #70, interviewed about medication and abuse incident |
| Physician #3 | Physician | Documented constipation and medication orders for Resident #70 |
| RNUM #1 | Registered Nurse Unit Manager | Observed medication administration to Resident #63 and interviewed about medication timing |
| LPN #6 | Licensed Practical Nurse | Medication nurse for Resident #63, interviewed about medication administration with meals |
| Medical Director | Medical Director | Interviewed about medication administration expectations for Resident #63 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 30, 2023
Visit Reason
Two isolated Level 2 deficiencies related to comprehensive care plan development and accident hazard prevention were identified and corrected.
Findings
Two isolated Level 2 deficiencies related to comprehensive care plan development and accident hazard prevention were identified and corrected.
Deficiencies (2)
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
One isolated Level 2 deficiency related to care plan timing and revision was identified and corrected.
Findings
One isolated Level 2 deficiency related to care plan timing and revision was identified and corrected.
Deficiencies (1)
Care plan timing and revision
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Apr 10, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident awareness of survey results, implementation of advance directives, notification of bed hold policies, assessment of significant changes in condition, development and implementation of care plans, respiratory care, medication regimen reviews, medication error rates, infection control practices, and sanitation of the trash compactor area.
Deficiencies (12)
F 0577: Residents were not aware of the location of the most recent survey results, which were placed in an area not readily accessible to the public.
F 0578: The facility did not ensure that advance directives for Resident #104 were effectively implemented, as the DNR identifier was missing from the resident's ID band and paper chart.
F 0625: The facility failed to provide written notification of the bed hold policy to residents and/or their representatives upon transfer or discharge for Residents #119 and #183.
F 0637: The facility did not complete a significant change Minimum Data Set (MDS) for Resident #104 after a decline in Activities of Daily Living was identified.
F 0656: Resident #28 did not have comprehensive care plans with measurable goals and interventions for respiratory and diabetic needs.
F 0657: Resident #62 was not consistently invited to care plan meetings after the initial meeting.
F 0695: Staff did not follow proper protocol for care and maintenance of a BI-PAP machine for Resident #28, including failure to change tubing weekly.
F 0756: The facility did not ensure a licensed pharmacist performed a monthly drug regimen review for Resident #104 in February 2019.
F 0758: Duplicate antidepressant therapy occurred for Resident #104 for 12 days due to failure to communicate psychiatrist's recommendation to discontinue Cymbalta to the primary medical doctor.
F 0759: Medication error rate exceeded 5%, with Resident #4 receiving incorrect allergy medication and insufficient Vitamin C dosage.
F 0814: The trash compactor area was not maintained in a sanitary condition, with garbage and refuse improperly contained and disposed.
F 0880: Facility staff failed to follow proper infection prevention practices including hand hygiene, gloving, and cleansing of blood glucose monitoring device, risking cross contamination during medication administration and wound care.
Report Facts
Medication error rate: 12
Days of duplicate medication therapy: 12
Days lapsed between drug regimen reviews: 45
Residents affected: 1
Residents affected: 5
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error finding and blood glucose monitoring device cleansing deficiency |
| LPN #2 | Licensed Practical Nurse | Named in infection control deficiency for failure to wash hands after resident contact |
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiency for cross contamination during medication pass |
| LPN #4 | Licensed Practical Nurse | Named in infection control deficiency for improper glove use during wound care |
| LPN #5 | Licensed Practical Nurse | Named in respiratory care deficiency for BI-PAP machine maintenance |
| LPN #6 | Licensed Practical Nurse | Named in advance directive deficiency and respiratory care deficiency |
| RN Manager #1 | Registered Nurse Manager | Named in medication error finding |
| RN Manager #2 | Registered Nurse Manager | Named in respiratory care and medication communication deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication regimen review and respiratory care |
| Director of Social Work | Director of Social Work | Named in bed hold notification deficiency |
| Social Worker | Social Worker | Named in care plan meeting invitation deficiency |
| Pharmacy Consultant | Pharmacy Consultant | Named in drug regimen review deficiency |
| Primary Medical Doctor | Primary Medical Doctor | Named in medication communication deficiency |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 7, 2017
Visit Reason
The inspection was a recertification survey to assess compliance with care planning, treatment of pressure ulcers, and medication management in the nursing facility.
Findings
The facility failed to develop timely and comprehensive care plans with measurable goals for residents' diabetes management, urinary incontinence, and medication use. Additionally, the facility did not provide timely treatment to prevent or heal pressure ulcers, including addressing nutritional decline impacting wound healing.
Deficiencies (2)
F 0279: The facility did not develop comprehensive care plans with measurable objectives and timely interventions for diabetes mellitus, urinary incontinence, and use of diuretics for several residents.
F 0314: The facility failed to provide timely care and treatment to prevent new or heal existing pressure ulcers, including addressing a resident's decline in caloric and protein intake impacting wound healing.
Report Facts
Resident weight decline: 11
Blood glucose level: 277
Pressure ulcer measurements: 2.3
Pressure ulcer measurements: 1.6
Supplement intake: 8
Supplement intake: 2
Calorie intake: 743
Protein intake: 37
Weight decline: 9.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Unit Registered Nurse Manager | Interviewed regarding lack of timely development of diabetes care plan and use of Lasix |
| RN #2 | Unit Manager | Interviewed regarding resident urinary incontinence |
| Physician | Interviewed about frequency of blood glucose monitoring for resident #185 | |
| Dietitian | Interviewed regarding resident #185's nutritional intake and delay in addressing supplement decline |
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