Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Point Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with anxiety, depression, and mild cognitive impairment refused care multiple times, but staff continued to provide care, leading to agitation and combative behavior. Despite the resident's clear refusals, staff insisted on washing and reapplying leg wraps, which the resident resisted. The DON confirmed that staff should have honored the resident's refusals and reapproached later.
A resident with anxiety and cognitive impairment refused a shower, leading to an altercation where an LPN pushed wet washcloths into the resident's face and CNAs held the resident's hands while the LPN provided care. The facility's investigation confirmed the abuse, and the actions of the CNAs were noted as potentially restraining the resident.
The facility failed to ensure all allegations of abuse were thoroughly investigated and did not prevent further potential abuse for a resident. An LPN continued to have access to residents after an alleged abuse incident, and the resident was not assessed timely. Additionally, some allegations were not investigated.
A facility failed to vaccinate 44 eligible residents with the pneumococcal vaccine despite their consent and medical orders. This failure resulted from a denied purchase request by the fiscal officer due to cost, and the Medical Director was not informed of the vaccine's unavailability. Consequently, seven residents were diagnosed with pneumonia, and one was hospitalized twice. The facility had policies for vaccine administration, but cost constraints delayed procurement, affecting residents with documented vulnerabilities to pneumonia.
A facility failed to provide adequate supervision to prevent accidents involving residents. Resident diagnosed with frontotemporal neurocognitive disorder and aphasia exhibited wandering, physical aggression, and sexually inappropriate behaviors. Incidents included physical aggression causing a hip fracture and sexually inappropriate actions towards other residents. Despite care plan modifications and medication adjustments, the resident continued to display harmful behaviors, resulting in harm to peers.
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to provide safe and effective care. Four nurses did not receive routine competency evaluations in key areas such as venous access devices, wound VACs, hand hygiene, and medication administration. Staff interviews confirmed the lack of proper training and competency assessments.
The facility failed to ensure annual performance evaluations for five certified nurse aides, as required by their policy. Interviews revealed that the aides had not received evaluations in over a year, and the Director of Nursing acknowledged the lapse.
The facility's governing body failed to establish and implement effective management policies, leading to delays in procuring pneumococcal vaccines and multiple deficiencies, including an immediate jeopardy in Influenza and Pneumococcal Immunizations (F883). Communication breakdowns and procedural issues were identified as contributing factors.
The facility failed to ensure the safe administration of IV fluids for a resident, leading to deficiencies in catheter care, documentation, and staff competency. The resident's care plan did not include necessary monitoring, and staff were unaware of the catheter type, resulting in inconsistent care and documentation.
A resident with a wound VAC device was not provided care according to professional standards and the care plan. The device was found unplugged and not functioning, and staff failed to properly monitor and manage it, leading to a deficiency in care.
A resident with pneumonia and sepsis was given an incomplete dose of an IV antibiotic, experienced a late administration, and did not have their IV access site flushed as ordered. The facility's policies on medication administration and IV therapy were not followed, leading to these deficiencies. Observations and interviews confirmed lapses in infection control and medication administration protocols.
An LPN failed to perform hand hygiene between medication administrations for four residents, despite facility policies requiring it. This oversight was observed multiple times, and the LPN acknowledged the failure, which could potentially spread germs.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility did not promote and facilitate the resident's right to self-determination through support of resident choice, specifically for one resident who refused care multiple times. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment, had intact cognitive function and required substantial assistance with daily activities. Despite the resident's refusals, staff continued to provide care, leading to the resident becoming agitated and combative. On the day of the incident, the resident refused to take a shower, but staff insisted and attempted to provide care against the resident's wishes. The resident became increasingly agitated, hitting the nurse and expressing a desire to be left alone. The nurse and aides continued to insist on providing care, including washing the resident and reapplying leg wraps, despite the resident's clear refusals and agitation. Interviews with staff and the resident confirmed that the resident's refusals were not honored, and inappropriate measures were taken, such as holding the resident's hands, which could be considered restraining. The Director of Nursing stated that staff should have ensured the resident's safety and left them alone when they refused care, rather than continuing to insist on providing care. The facility's actions were inconsistent with the resident's right to self-determination and choice.
Resident Abuse Incident Involving LPN and CNAs
Penalty
Summary
The facility did not ensure that residents were free from abuse, as evidenced by an incident involving a resident with anxiety disorder, major depressive disorder, and mild cognitive impairment. The resident, who required substantial assistance with daily activities, refused a shower, leading to an altercation with a licensed practical nurse (LPN). The LPN pushed multiple wet washcloths into the resident's face when the resident declined care, and certified nurse aides (CNAs) held the resident's hands while the LPN provided care that the resident had refused. The facility's investigation revealed that the LPN attempted to remove the resident's leg wraps, causing the resident to become agitated and hit the nurse. The LPN responded by wringing out wet washcloths over the resident's head and shoving them into the resident's face. Despite the resident's resistance, the LPN continued to insist on applying the leg wraps, with the assistance of CNAs who held the resident's hands to prevent them from hitting the nurse. The resident reported feeling angry and restrained during the incident but did not express fear of staff afterward. Interviews with staff and the resident confirmed the sequence of events, with the Director of Nursing concluding that the LPN had abused the resident. The CNAs' actions of holding the resident's hands were noted, with one CNA describing it as a friendly gesture, while another CNA's involvement was seen as potentially restraining the resident. The facility's abuse prevention policy was not followed, leading to the deficiency.
Failure to Investigate and Prevent Further Abuse
Penalty
Summary
The facility did not ensure all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and did not ensure further potential abuse was prevented for one resident. Specifically, a certified nurse aide witnessed alleged abuse by an LPN towards a resident and did not report the alleged abuse immediately, resulting in the LPN continuing to have access to residents for the remainder of the shift while the investigation was pending. Additionally, statements from staff documented additional potential abuse, and those allegations were not investigated. The resident was not assessed by a qualified professional timely following the allegation of abuse. The facility's Abuse Prevention Policy and Abuse Reporting and Investigation policy required immediate reporting of any suspected or witnessed abuse to a supervisor, immediate assessment of the resident by a registered nurse, and thorough documentation and investigation of all allegations. However, the incident involving the resident occurred between 4:00 AM and 4:45 AM, and the certified nurse aide did not report it until 7:00 AM. The LPN involved continued to work until the end of their shift at 7:30 AM, and there was no documented evidence that the LPN was prevented from having access to the resident or other residents following the incident. The resident was not assessed until approximately 10:30 AM, several hours after the incident was reported. Interviews with staff revealed that the certified nurse aide who witnessed the alleged abuse did not feel comfortable reporting the incident immediately and was unaware of the policy requiring immediate reporting. The Director of Nursing acknowledged the importance of immediate reporting and assessment to ensure resident safety but did not address the delayed reporting with the certified nurse aide. Additionally, the Director of Nursing did not investigate the allegation that another certified nurse aide held the resident's hands during the incident, which could be considered a means of restraint. The delay in reporting and assessment, as well as the failure to investigate all allegations, contributed to the deficiency in ensuring resident safety and thorough investigation of abuse allegations.
Pneumococcal Vaccination Deficiency Due to Procurement Issues
Penalty
Summary
During the recertification survey conducted from 3/18/2024 to 3/29/2024, it was identified that the facility failed to vaccinate 44 eligible residents with the pneumococcal vaccination, despite their consent and medical orders to receive the vaccine. This failure put these residents at risk for serious harm or death, as evidenced by seven residents being diagnosed with pneumonia and one resident being hospitalized twice for pneumonia treatment. The facility's request to purchase the pneumococcal vaccine was denied by the fiscal officer due to cost, and the Medical Director was not informed of the unavailability of the vaccine, leading to a breakdown in communication and procurement processes. The facility's policies related to purchase orders, electronic medical record orders, physician notifications, and standing orders for administering pneumococcal vaccines were in place, outlining the necessary procedures for vaccine administration. However, despite having the necessary approvals and requests in place, the facility faced challenges in obtaining the pneumococcal vaccine due to cost constraints. This resulted in a delay in vaccine procurement, ultimately leading to the failure to vaccinate the identified residents who had consented to receive the vaccine. Multiple residents, such as Resident #95 and Resident #215, had documented medical histories and conditions that made them particularly vulnerable to pneumonia, highlighting the critical importance of timely vaccination. Despite physician orders and resident consents for the pneumococcal vaccine, the facility's inability to secure the vaccine in a timely manner resulted in these residents not receiving the necessary protection against pneumonia, putting their health and well-being at risk.
Inadequate Supervision Leading to Resident Harm Due to Aggressive Behaviors
Penalty
Summary
During the recertification and abbreviated surveys conducted from 3/18/2024 to 3/29/2024 at a nursing home facility, it was found that the facility failed to provide adequate supervision to prevent accidents for several residents. Specifically, Residents #114, #191, and #213 were subjected to physical aggression and sexually abusive behaviors by Resident #174. Resident #174, diagnosed with frontotemporal neurocognitive disorder and aphasia, exhibited behaviors such as wandering, physical aggression, and sexually inappropriate actions towards other residents. Despite documented incidents of aggressive and inappropriate behaviors, the facility's care plan for Resident #174 did not include sufficient interventions to prevent harm to other residents. The deficiency report highlighted incidents where Resident #174 pushed Resident #114, causing a hip fracture, and engaged in sexually inappropriate behaviors with Residents #191 and #213. Nursing progress notes detailed instances of Resident #174 exhibiting aggressive behaviors, inappropriate sexual behaviors, and physical aggression towards peers. Despite modifications to the care plan and medication adjustments, Resident #174 continued to display behaviors that put other residents at risk of harm. The facility's failure to effectively address and prevent these behaviors led to incidents resulting in harm to Residents #114, #191, and #213.
Deficiency in Nurse Competency Evaluations
Penalty
Summary
The facility did not ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents' safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, four licensed nurses did not receive routine competency evaluations covering key skill-set areas, including accessing venous access devices, vacuum-assisted wound closure devices (wound VACs), hand hygiene, and medication administration. Deficiencies were identified in the areas of Parenteral/IV fluids, Free from Significant Medication Errors, Quality of Care, and Infection Control. The facility's training documents and policies indicated that annual in-services and competencies were scheduled monthly throughout the year. However, the records showed that the most current annual competencies for the reviewed licensed nurses were either incomplete or missing. For instance, one LPN had orientation competencies completed but lacked documented competencies for medication administration skills, administration through an intravenous access device, intravenous access device identification, or wound vacuums. Similar gaps were found for other nurses, including a registered nurse and two other LPNs. Interviews with staff revealed that the facility had not conducted medication administration trainings or competencies, and intravenous skills training was not provided by the staff development coordinator. Competencies were often marked as
Failure to Conduct Annual Performance Evaluations for Certified Nurse Aides
Penalty
Summary
The facility did not ensure certified nurse aide performance reviews were completed once every 12 months for five certified nurse aides. Specifically, there was no documented evidence that certified nurse aides #35, #41, #42, #43, and #44 had performance reviews at least once every 12 months. The facility policy titled Staff Evaluations, last modified on 11/9/2018, stated that all staff members would receive an annual performance evaluation, and any identified areas of weakness would be referred to staff education for performance improvement. However, the last documented performance evaluations for the nurse aides were dated between 12/29/2021 and 2/22/2023, indicating that the required annual evaluations were not conducted as per policy. During interviews, the Administrator confirmed that certified nurse aides were required to have 12 hours of in-service training annually, with an annual performance evaluation and in-services based on their evaluation deficiencies. Certified nurse aides interviewed stated they had not received performance evaluations in over a year, with some indicating it had been a couple of years since their last evaluation. The Director of Nursing and Assistant Director of Nursing acknowledged that the performance evaluations for certified nurse aides were not being completed as required, despite the Personnel Coordinator tracking and notifying Clinical Care Coordinators when evaluations were due. The deficiency was confirmed by the surveyors based on record reviews and staff interviews.
Failure to Implement Effective Management Policies
Penalty
Summary
The facility's governing body failed to establish and implement policies regarding the management and operation of the facility, leading to inconsistent communication between the governing body and the facility Administrator. This lack of communication resulted in multiple deficiencies, including an immediate jeopardy in Influenza and Pneumococcal Immunizations (F883). The facility's Quality Assurance Performance Improvement Committee (QAPI) Plan outlined responsibilities for clinical care improvement and resource allocation, but these were not effectively executed. Specifically, the policy required a member of the facility Advisory Board to participate in the committee and provide monthly status reports, which did not occur as intended. An email chain revealed delays in the procurement of pneumococcal vaccines due to fiscal approval processes. The Infection Preventionist's request for vaccines was delayed because the purchase order exceeded $10,000, requiring additional approval. The Deputy Administrator of Fiscal Services and the facility accountant exchanged emails questioning the pricing and approval process, which led to a significant delay in obtaining the necessary vaccines. The Administrator eventually authorized the purchase using a personal credit card to expedite the process. Interviews with the Assistant Director of Nursing and the Deputy Administrator of Fiscal Services confirmed the procedural issues and communication breakdowns that contributed to the deficiency.
Failure to Ensure Safe Administration of IV Fluids
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, leading to several deficiencies. Specifically, the resident had an intravenous access device, but the physician orders did not include the length of the external catheter or directions for measuring the catheter to ensure it did not migrate or dislodge. Licensed nurses were unaware of the type of catheter the resident had, and documentation of catheter care was inconsistent. Additionally, the care plan did not include daily care and monitoring of the device, and deficiencies related to intravenous therapy were identified in the areas of Significant Medication Errors and Competent Nursing Staff. The resident had diagnoses including pneumonia and sepsis and required intravenous antibiotic therapy. However, there was no documented evidence of a measurement of the external catheter length, and the comprehensive care plan did not include the use of intravenous fluids, intravenous medications, or the presence of an active intravenous access device. Multiple interviews with nursing staff revealed confusion and lack of knowledge regarding the type of intravenous access device the resident had, and there were inconsistencies in following the facility's policies for intravenous therapy. The facility's policies required specific actions such as measuring the external catheter length and arm circumference, changing the dressing weekly, and documenting these actions in the electronic treatment administration record. However, these actions were not consistently performed or documented. Interviews with various nursing staff and the Medical Director highlighted a lack of communication and clarification regarding the type of intravenous access device and the necessary care procedures, leading to the identified deficiencies.
Failure to Maintain VAC Device for Resident
Penalty
Summary
The facility did not ensure that Resident #223 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the resident had an order for a vacuum-assisted closure (VAC) device for wound healing, which was observed unplugged and not functioning. The facility policy required the VAC device to be in optimum working order and checked every shift, but this was not adhered to in the case of Resident #223. Resident #223 was admitted with diagnoses including surgical aftercare following a panniculectomy and an unspecified open wound of the abdominal wall. The resident's care plan included the use of a VAC device with specific instructions for its maintenance and monitoring. However, upon the resident's return from the emergency department after a fall, there was no documented evidence that the VAC device was assessed or functioning. Observations revealed that the device was off, unplugged, and contained a trace amount of drainage, indicating it was not in use as required. Interviews with staff revealed a lack of awareness and proper handling of the VAC device. Certified nurse aides and licensed practical nurses did not adequately monitor or manage the device, and there was confusion about the appropriate actions to take when the device was found off. The resident expressed concerns about the device not being checked, and it was only after the occupational therapist alerted a registered nurse that the device was turned back on. This failure to maintain the VAC device in working order and to follow the care plan led to a deficiency in the treatment and care provided to Resident #223.
Significant Medication Errors for Resident
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for Resident #207. The resident, who had diagnoses including pneumonia and sepsis, was given an incomplete dose of an intravenous antibiotic, experienced a late administration of the antibiotic, and did not have their intravenous access site flushed as ordered. The facility's policies on medication administration and intravenous therapy were not followed, leading to these deficiencies. Observations revealed that the intravenous medication bag was not fully emptied, and the tubing was not properly capped, indicating lapses in infection control and medication administration protocols. The Medication Administration Record (MAR) showed discrepancies in the timing and completeness of the antibiotic doses. For instance, the ceftriaxone dose on 3/16/2024 was administered more than 24 hours after the previous dose, and the sodium chloride flush was not documented as administered on 3/15/2024. Interviews with nursing staff and the Assistant Director of Nursing confirmed that these lapses were medication errors. The staff admitted to not following the proper procedures for verifying and administering intravenous medications, including not ensuring the medication bag was empty and not documenting the flushes correctly. Further interviews with the Medical Director and other nursing staff highlighted that the orders for intravenous medications were incomplete, lacking infusion rates, and that the staff failed to seek clarification from the provider. The late and incomplete doses were not reported to the provider, which could have led to potential harm to the resident. The facility's failure to adhere to its own policies and procedures for medication administration and intravenous therapy resulted in significant medication errors for Resident #207.
Failure to Perform Hand Hygiene Between Medication Administrations
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, leading to the potential development and transmission of communicable diseases and infections. Specifically, a licensed practical nurse (LPN) failed to perform hand hygiene between medication administrations for four residents. The facility's policies on medication administration and hand hygiene, last modified in 2020, clearly documented that hand hygiene should be performed before preparing medications and between resident contacts. However, the LPN did not adhere to these policies during the observed medication administration process for Residents #3, #147, #195, and #212. During the medication administration process, the LPN handled various medications and personal items such as a pen and clipboard without performing hand hygiene. This was observed multiple times between 9:36 AM and 10:06 AM. The LPN acknowledged the oversight during an interview, stating that they had sanitizer available but did not use it between residents, which could potentially spread germs. The Infection Preventionist confirmed that proper hand hygiene should be performed between all residents and after known exposure to soiled items to prevent the spread of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Vestal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Susquehanna Nursing & Rehabilitation Center, L L C | 0.7 mi | ★★★★★ | 1 | 0 |
| James G Johnston Memorial Nursing Home | 3.3 mi | — | 0 | 0 |
| Elizabeth Church Manor Nursing Home | 3.3 mi | ★★★★★ | 0 | 0 |
| Vestal Park Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Village At Endwell | 4.4 mi | ★★★★★ | 6 | 0 |
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