Inspection Reports for
Willow Point Rehabilitation and Nursing Center
3700 Old Vestal Road, Vestal, NY, 13850
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Inspection Report — Jun 13, 2025
Annual Inspection CMS
Date: Jun 13, 2025
Visit Reason
The inspection was a recertification survey conducted from June 9, 2025 to June 13, 2025, to assess compliance with regulatory requirements for Willow Point Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident privacy violations, incomplete care plans, inadequate assistance with activities of daily living, failure to accommodate resident food preferences, improper food storage and handling, and lapses in infection control practices.
Citations (6)
F 0583: The facility did not ensure resident rights to personal privacy and confidentiality of medical records for four residents, as identifying information was posted in a public area visible to others.
F 0656: The facility failed to develop and implement a comprehensive care plan for one resident to include anticoagulant therapy and associated risks.
F 0677: The facility did not provide necessary facial grooming/shaving care for two residents unable to perform activities of daily living.
F 0806: The facility did not ensure accommodation of resident food preferences for two residents, as preferred food items were missing from their meal trays.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served according to professional standards, including use of dented cans, improper dish drying, expired/unlabeled food, food stored too close to ceiling, and uncovered food during transport.
F 0880: The facility failed to maintain an infection prevention and control program, as a food service aide did not perform hand hygiene after removing gloves during meal service.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 2
Dented cans observed: 3
Expired food servings: 12
Unlabeled food containers: 8
Dishware count: 60
Dishware count: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #18 | Named in privacy violation finding regarding posted resident information | |
| Registered Nurse Unit Manager #20 | Named in privacy violation finding regarding posted resident information | |
| Corporate Compliance Officer | Named in privacy violation finding regarding resident information confidentiality | |
| Director of Social Worker | Named in privacy violation finding regarding resident information confidentiality | |
| Certified Nurse Aide #8 | Named in care plan and grooming deficiencies | |
| Licensed Practical Nurse #9 | Named in care plan and grooming deficiencies | |
| Clinical Care Coordinator #15 | Named in care plan and grooming deficiencies | |
| Director of Nursing | Named in care plan deficiency | |
| Certified Nurse Aide #38 | Named in grooming deficiency for Resident #226 | |
| Registered Dietitian #31 | Named in food preference deficiency | |
| Food Service Worker #36 | Named in food preference deficiency | |
| Food Service Worker #35 | Named in food preference deficiency | |
| Kitchen General Manager #28 | Named in food storage and infection control deficiencies | |
| Food Service Associate #27 | Named in infection control deficiency for failure to perform hand hygiene | |
| Licensed Practical Nurse Infection Control Preventionist #29 | Named in infection control deficiency | |
| Certified Nursing Aide #23 | Named in uncovered food transport observations | |
| Unit Helper #17 | Named in uncovered food transport observations | |
| Certified Nursing Aide #24 | Named in uncovered food transport observations | |
| Certified Nursing Aide #25 | Named in uncovered food transport observations | |
| Certified Nursing Aide #26 | Named in uncovered food transport observations | |
| Licensed Practical Nurse #19 | Named in uncovered food transport observations |
Inspection Report — Jun 13, 2025
State
Date: Jun 13, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2025 with citation and enforcement history.
Complaint Details
The state logged 123 complaints about this facility; 11 led to on-site inspections. Complaint-related citations numbered 9.
Findings
Across 7 inspections, 5 resulted in citations totaling 52, including standard health and Life Safety Code violations. The facility had 4 enforcement actions with fines totaling $46,000 and multiple citations of varying severity levels.
Citations (44)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Personal Privacy/confidentiality Of Records was deficient.
Standard Health Citation — quality of care: Resident Allergies, Preferences, Substitutes was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extens was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was deficient.
Life Safety Code Citation — NFPA requirements: Elevators was deficient.
Life Safety Code Citation — NFPA requirements: Exit Signage was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors was deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General was deficient.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies - Construction Type was deficient.
Life Safety Code Citation — NFPA requirements: Plan Based On All Hazards Risk Assessment was deficient.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures was deficient.
Life Safety Code Citation — NFPA requirements: Utilities - Gas And Electric was deficient.
Standard Health Citation — quality of care: Free From Abuse And Neglect was deficient.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation was deficient.
Standard Health Citation — quality of care: Self-determination was deficient.
Standard Health Citation — quality of care: Competent Nursing Staff was deficient.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient.
Standard Health Citation — quality of care: Governing Body was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Influenza And Pneumococcal Immunizations was deficient.
Standard Health Citation — quality of care: Nurse Aide Peform Review-12 Hr/yr In-service was deficient.
Standard Health Citation — quality of care: Parenteral/iv Fluids was deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors was deficient.
Life Safety Code Citation — NFPA requirements: Cooking Facilities was deficient.
Life Safety Code Citation — NFPA requirements: Discharge From Exits was deficient.
Life Safety Code Citation — NFPA requirements: Egress Doors was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie was deficient.
Standard Health Citation — quality of care: Bedrails was deficient.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors was deficient.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 52
Inspections with violations: 5
Inspections without violations: 2
Total complaints: 123
On-site complaint inspections: 11
Citations issued from complaints: 9
Enforcement actions: 4
Total fines: 46000
Inspection Report — Apr 30, 2024
Abbreviated Survey CMS
Date: Apr 30, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with resident rights, abuse prevention, and appropriate response to alleged violations following a complaint and incident involving Resident #1.
Complaint Details
The investigation was complaint-related, triggered by allegations of abuse involving Resident #1. The complaint was substantiated with findings of abuse by licensed practical nurse #4 and failures in timely reporting and investigation by staff and administration.
Findings
The facility failed to promote and facilitate resident self-determination and choice, resulting in care being provided against Resident #1's refusals. Licensed practical nurse #4 was found to have abused Resident #1 by forcibly applying care and shoving wet washcloths into the resident's face. The facility also failed to thoroughly investigate all allegations of abuse and did not prevent further potential abuse during the investigation.
Citations (3)
F 0561: The facility did not promote resident self-determination and choice, providing care to Resident #1 despite multiple refusals.
F 0600: Licensed practical nurse #4 physically abused Resident #1 by shoving wet washcloths into the resident's face and staff held the resident's hands during care the resident declined.
F 0610: The facility failed to respond appropriately to alleged violations; delayed reporting and investigation allowed licensed practical nurse #4 to continue resident care during the investigation.
Report Facts
Residents Affected: 1
Date of Incident: Apr 12, 2024
Date of Survey Completion: Apr 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in abuse findings for forcibly providing care and shoving washcloths into resident's face |
| Certified Nurse Aide #5 | Certified Nurse Aide | Witnessed abuse and held resident's hands during care; reported incident to supervisor |
| Certified Nurse Aide #6 | Certified Nurse Aide | Held resident's hands during care and was involved in incident; not interviewed about incident |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse findings and failure to ensure timely reporting and investigation |
| Registered Nurse #8 | Registered Nurse | Conducted resident assessment following abuse allegation |
| Registered Nurse Manager #9 | Registered Nurse Manager | Documented resident's statement and involved in assessment |
| Licensed Practical Nurse Supervisor #7 | Licensed Practical Nurse Supervisor | Received abuse report from Certified Nurse Aide #5 and notified Director of Nursing |
Inspection Report — Mar 29, 2024
Complaint Investigation CMS
Date: Mar 29, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to investigate complaints and assess compliance with regulatory standards.
Complaint Details
The complaint investigation revealed substantiated findings including failure to maintain wound care device function, inadequate supervision leading to resident injuries, medication administration errors, and lapses in infection control practices.
Findings
The facility failed to provide appropriate treatment and care for a resident with a wound vacuum assisted closure device, failed to prevent resident-to-resident abuse resulting in physical harm, and failed to ensure residents were free from significant medication errors and proper infection control practices.
Citations (4)
F0684: The facility did not ensure a wound vacuum assisted closure device was functioning continuously as ordered for Resident #223, resulting in potential delayed wound healing.
F0689: The facility failed to provide adequate supervision to prevent accidents and resident-to-resident abuse, resulting in a hip fracture and head abrasion for residents.
F0760: The facility failed to ensure timely and complete administration of intravenous antibiotics for Resident #207, including missed flushes and late doses.
F0880: Licensed practical nurse #45 failed to perform hand hygiene between medication administrations to multiple residents, risking infection transmission.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Medication administration error count: 3
Medication administration time window: 1
Intravenous antibiotic dose: 2
Intravenous flush volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #45 | Licensed Practical Nurse | Failed to perform hand hygiene between medication administrations |
| Registered Nurse #30 | Registered Nurse | Assessed wound vacuum assisted closure device and documented wound care |
| Nurse Practitioner #40 | Nurse Practitioner | Provided clinical insight on wound vacuum assisted closure device and medication errors |
| Licensed Practical Nurse #31 | Licensed Practical Nurse | Administered intravenous antibiotics and reported medication administration process |
| Certified Nurse Aide #22 | Certified Nurse Aide | Provided information on resident-to-resident incident prevention and door sensor usage |
| Registered Nurse Manager #24 | Registered Nurse Manager | Documented and managed resident-to-resident abuse incidents |
| Licensed Practical Nurse Clinical Care Coordinator #32 | Licensed Practical Nurse Clinical Care Coordinator | Provided details on intravenous medication administration and errors |
| Medical Director | Medical Director | Confirmed medication order expectations and error reporting |
| Director of Nursing | Director of Nursing | Discussed supervision expectations and resident safety |
Inspection Report — Mar 29, 2024
Annual Inspection CMS
Date: Mar 29, 2024
Visit Reason
The survey was a recertification and abbreviated inspection conducted to assess compliance with regulatory requirements for Willow Point Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including treatment and care related to wound vacuum assisted closure devices, prevention of resident-to-resident abuse and accidents, intravenous therapy administration, nurse competencies, medication administration errors, infection control practices, and pneumococcal vaccination compliance. An immediate jeopardy was identified and later removed after corrective actions were taken.
Citations (9)
F0684: The facility failed to ensure proper functioning and monitoring of a wound vacuum assisted closure device for Resident #223, resulting in the device being unplugged and not functioning as ordered.
F0689: The facility failed to provide adequate supervision to prevent accidents and abuse among residents, resulting in physical harm including a hip fracture and head abrasion to residents caused by another resident's aggressive behaviors.
F0694: The facility failed to ensure safe and appropriate administration of intravenous fluids and medications for Resident #207, including incomplete medication doses, lack of catheter measurement, and inconsistent documentation.
F0726: The facility failed to ensure licensed nurses had documented competencies in key nursing skills including intravenous therapy, wound vacuum devices, hand hygiene, and medication administration.
F0730: The facility failed to complete annual performance evaluations for certified nurse aides as required, with 5 aides lacking evaluations within the past 12 months.
F0760: The facility failed to ensure residents were free from significant medication errors, including late and incomplete intravenous antibiotic doses and missed intravenous flushes for Resident #207.
F0837: The facility's governing body failed to establish and implement policies ensuring regulatory compliance, including failure to timely procure pneumococcal vaccines leading to an immediate jeopardy.
F0880: The facility failed to maintain an effective infection prevention and control program, evidenced by licensed practical nurse #45 not performing hand hygiene between medication administrations to multiple residents.
F0883: The facility failed to vaccinate 44 eligible residents with the pneumococcal vaccine due to delayed procurement and poor communication, resulting in an immediate jeopardy to resident health and safety.
Report Facts
Residents not vaccinated with pneumococcal vaccine despite consent: 44
Certified nurse aides lacking annual performance evaluations: 5
Medication administration errors: 3
Residents affected by wound vacuum device deficiency: 1
Residents affected by resident-to-resident abuse and accidents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #45 | Licensed Practical Nurse | Named in infection control deficiency for failure to perform hand hygiene during medication administration. |
| Licensed Practical Nurse #31 | Licensed Practical Nurse | Named in medication administration errors and intravenous therapy deficiencies. |
| Licensed Practical Nurse #32 | Licensed Practical Nurse Clinical Care Coordinator | Named in intravenous therapy and medication administration deficiencies. |
| Registered Nurse #30 | Registered Nurse | Named in intravenous therapy and wound vacuum device deficiencies. |
| Nurse Practitioner #40 | Nurse Practitioner | Provided clinical input on wound vacuum device and intravenous therapy deficiencies. |
| Administrator #1 | Facility Administrator | Named in governance and pneumococcal vaccine procurement deficiencies. |
| Deputy Administrator of Fiscal | Deputy Administrator of Fiscal Services | Named in pneumococcal vaccine procurement and purchasing delays. |
| Licensed Practical Nurse/Infection Preventionist #5 | Licensed Practical Nurse/Infection Preventionist | Named in infection control and pneumococcal vaccine procurement deficiencies. |
Inspection Report — Jan 2, 2024
Abbreviated Survey CMS
Date: Jan 2, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations regarding the use of bed rails and resident safety in the facility.
Findings
The facility failed to assess residents for risk of entrapment from bed rails prior to installation, did not review risks and benefits with residents or their representatives, and did not obtain informed consent for bed rail use for 3 residents. Care plans did not include use and monitoring of bed rails as required.
Citations (1)
F 0700: The facility did not assess residents for safety risks related to bed rails, did not review risks and benefits with residents or representatives, and did not obtain informed consent prior to bed rail installation for 3 residents. Care plans lacked documentation of bed rail use and monitoring.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding bed rail assessments and care plans |
| Registered Nurse #5 | Registered Nurse | Documented resident education on risks and benefits of bed rails |
| Certified Nurse Aide #1 | Certified Nurse Aide | Provided information on bed rail use and resident care |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Provided information on care plans and bed rail use |
| Physical Therapist Director of Rehabilitation #3 | Physical Therapist Director of Rehabilitation | Discussed resident evaluations and bed rail assessments |
Inspection Report — Oct 29, 2021
Annual Inspection CMS
Date: Oct 29, 2021
Visit Reason
The inspection was a recertification survey conducted from 10/25/21 to 10/29/21 to assess compliance with regulatory requirements for Willow Point Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to complete PASARR screenings prior to admission, failure to include a resident in care plan meetings, inadequate assistance with activities of daily living, unsafe reheating of food leading to a resident burn, unsafe hot water temperatures, failure to provide necessary behavioral health care, expired medications in storage, and unsanitary kitchen conditions with unlabeled and outdated food items.
Citations (7)
F0645: The facility failed to ensure PASARR screening for mental disorders or intellectual disabilities was completed prior to admission for 2 of 35 residents reviewed.
F0657: The facility failed to ensure participation of the resident in the comprehensive care plan meeting for 1 of 1 resident reviewed.
F0677: The facility failed to provide incontinence care as planned and observed a resident inappropriately dressed.
F0689: The facility failed to maintain a safe environment to prevent accidents, including a resident burn from spilled hot oatmeal and hot water temperatures exceeding 120°F in resident bathrooms and shower rooms.
F0740: The facility failed to provide necessary behavioral health care and services for 1 of 6 residents reviewed who was withdrawn, refusing food and medications, and lacked a behavioral health referral as ordered.
F0761: The facility failed to label drugs and biologicals properly and did not dispose of expired medications and biologicals in the medication room and medication cart on South 2B unit.
F0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unsanitary kitchen conditions with standing water and worms, stained ceiling tiles, and multiple unlabeled and outdated food items.
Report Facts
Residents reviewed for PASARR screening: 35
Weight loss: 5.2
Water temperature: 122
Expired medication dates: 3
Food storage duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Named in expired medication storage observation |
| LPN Manager #9 | Licensed Practical Nurse Manager | Responsible for medication expiration checks and education |
| NP #12 | Nurse Practitioner | Involved in behavioral health care and medication management for Resident #202 |
| Social Work Assistant #13 | Social Work Assistant | Documented resident behavioral health concerns and care plan discussions |
| CNA #36 | Certified Nursing Assistant | Observed providing inadequate incontinence care and dressing Resident #38 |
| LPN #14 | Licensed Practical Nurse | Involved in resident burn incident and subsequent care |
| Food Service Director | Provided information on kitchen conditions and food safety practices | |
| Maintenance Director | Provided information on water temperature and boiler maintenance |
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