Willow Creek Lodge

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. On 11/12/25, the facility failed to ensure the Direct Care Daily Staffing Numbers were posted. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include:An observation on 11/19/25 at 07:40 AM revealed, there was no posting of the facility Direct Care Staffing Numbers. The placard that held the posting at the front entrance was empty. An observation on 11/19/25 at 08:15 AM revealed, there was no posting of the facility Direct Care Staffing Numbers. The placard that held the posting at the front entrance was empty. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 5 residents (Resident #2, Resident #67, and Resident #83) reviewed for accuracy of assessments .- The facility failed to accurately assess Resident #2's use of antipsychotics on her Quarterly MDS dated [DATE].- The facility failed to accurately assess Resident #67's dialysis status and use of antiplatelets on her Admissions MDS dated [DATE].- The facility failed to accurately assess Resident #83's hospice status on her Quarterly MDS dated [DATE].

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 Residents (Resident #2 and Resident #67) reviewed for care plans.- The facility failed to include Resident #2's diagnosis of MDD in her care plan.- The facilitate failed to include Resident #67's diagnosis of hypotension (low blood pressure), CAD (buildup of fats & cholesterol on the walls of blood vessel), hyperlipidemia (high cholesterol) , COPD (disease that makes it hard to breath), GERD (acid reflux) and her use of antiplatelet (clopidogrel) on her care plan. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 5 residents (Resident #83) reviewed for dignity.- The facility failed to change Resident #83's sheets after an episode of urinary incontinence in the early morning on Saturday 07/12/25 leaving her lying on the soiled sheets.- The facility failed to launder Resident #83's bed sheets after an episode of urinary incontinence on Saturday 07/12/25 leaving the soiled sheets in a bag on a chair in her room until Tuesday 07/15/25. This failure could place residents at risk of feeling uncomfortable and disrespected.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review the facility failed to immediately consult with the resident's physician; when there wis an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #67 ) reviewed for change of condition. - The facility failed to notify Resident #67's physician after she sustained a nickel sized skin tear on 07/10/25. This failure could place residents at risk for not receiving appropriate care and interventions.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #2 and #77) reviewed for PASRR.- The facility failed to ensure Resident #2's diagnosis of Dementia and Mental Illness ( MDD and psychosis) were accurately documented in her PL1.- The facility failed to ensure Resident #77's diagnosis of Mental Illness (MDD) was accurately documented in his PL1. This failure could place residents who had a mental illness at risk of not receiving needed assessments (PASRR Evaluation), and individualized specialized services to meet their needs.

Inspectors wroteBased on interview, observation, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #96) reviewed for baseline care plan. - The facility failed to ensure Resident #96's baseline care plan addressed the resident's diagnoses of anxiety disorder and depression which were treated with medications, the presence of a pacemaker, his orders for the opioid pain medication morphine. This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, and services provided with could cause a physical or psychosocial decline in health.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 5 residents (Resident #67) reviewed for quality of care.- The facility failed to provide care to Resident #67 for 4 days after she suffered from a skin tear on 07/10/25. These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, infection and hospitalizationFindings included:Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 Resident (Resident #4)reviewed for enteral nutrition. - The facility failed to administer medications safely to Resident #4 via G-tube (a feeding tube inserted into the stomach through the abdomen) by not checking for placement and forcefully pushing fluids into the residents G-tube with a syringe. These failures could place residents at risk of injuries, and hospitalization.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents (Resident #11) reviewed for treatment and services for mental and psychosocial concerns.- The facility failed to provide mental health services to Resident #11 who was diagnosed with MDD resulting in the resident feeling sad, lonely and crying. These failures could place residents at risk of minor and major injuries, suicide threats, attempted suicide, hospitalization, and death.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #84) reviewed for infection control.- The facility failed to practice proper infection control when providing perineal care to Resident #84 following a bowel movement. These failures could place residents at risk of exposure to infection, decline in health and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 (Resident #1 and #2) residents reviewed for comprehensive assessments. The facility failed to develop and implement a care plan (dated 07/01/2025) that addressed Resident #1’s new diagnosis of chronic kidney disease after return from hospital on [DATE]. The facility failed to develop and implement a care plan (dated 07/02/2025) that addressed Resident #2’s allergy to lactose and a fall with injury on 06/02/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain correct chemical concentration , based on periodic testing, at least once per shift during the dishwasher's wash cycle in one of one kitchen. The facility failed to test and maintain proper concentration level of sanitizer solution during the dishwasher's wash cycle. This failure could affect all residents by placing them at risk for food-born illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop the comprehensive person-centered care plan with services furnished to maintain the resident's highest practicable physical well-being for 1 of 5 residents, (Resident #71), in that: -The facility failed to ensure Resident #71's care plan was not updated to reflect the resident's need for a urinary catheter care. -This failure placed residents at risk of not receiving adequate care. Findings Include: Record review of Resident #71 face sheet, dated 06/11/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnosis of infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #71 Minimum Data Set (MDS) dated [DATE] reflected BIMS score of 04, which indicated severe impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician supervised the care of a resident for one (Resident #71) of five residents reviewed for physician services in that: The facility failed to ensure the physician supervised and monitored Resident #71's indwelling urethral catheter since Resident #71 was diagnosed with infection and inflammatory reaction due to indwelling urethral catheter. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition, or illness up to and including death.

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record of one (Resident #1) out of four residents reviewed for discharge requirements. The facility failed to ensure that Resident #1's medical record had physician documentation to address why the resident was being discharged and what needs of the resident the facility could not meet. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmaceutical services. -The facility failed to accurately document on the MAR when the medication Hydromorphone solution (a medication for pain), was signed out on Resident #1's narcotic count sheet. This failure could place residents receiving medications at risk of inadequate therapeutic outcomes, uncontrolled pain, and uncontrolled anxiety.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply for 1 of 1 facility. -The facility's emergency water supply consisted of 225 gallons (45, 5-gallon jugs) of water on hand for a census of 76 residents and 104 employees stored in a shed behind the building. This failure could place residents at serious risk for complications from dehydration and sanitation.

Inspectors wroteBased on interviews and records reviewed, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 (Director of Food Services Manager, Housekeeping Manager, Certified Nurse Assistant M (CNA M), and Certified Nurse Assistant O (CNA O)) of 17 employees reviewed for employee misconduct registry (EMR)/nurse aide registry (NAR). -The facility failed to check the EMR/NAR annually for 4 of 17 employees. This failure could place residents at an increased risk of abuse, neglect, exploitation, and/or misappropriation of property.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #22) reviewed for beneficiary notices. The facility failed to give Resident #22 a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when she was discharged from skilled services at the facility before her covered days were exhausted. This failure could place residents at risk of not being fully informed about services covered by Medicare.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #37) of eight residents reviewed for falls. The facility failed to prevent Resident #37's avoidable accident when the anti-tippers (bars that prevent the wheelchair from falling over) were positioned incorrectly on his wheelchair. Resident #37 was transferred from his bed to his wheelchair and fell backwards, hitting his head and sustaining pain to the left knee. The facility failed to ensure Resident #37 was assessed for injuries by a nurse prior to being picked up from the floor. This failure could place residents at risk for injury, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #12) reviewed for nutrition. The facility failed to ensure Resident #12's tube feeding order was entered correctly. Resident #12 was receiving feeding over 20 hours instead of 22 hours as verbally ordered by the Physician. This failure could place residents in the facility at risk of not having their nutritional needs addressed and/or met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 1 of 6 residents (Resident #25) reviewed for medication errors. MA C administered Resident #231's Refresh Tears (eye drops) to Resident #25 and administered the wrong amount of Refresh Tears to Resident #25. MA C administered one Docusate (a stool softener) to Resident #25 instead of two as prescribed by the Physician. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.