Willow Creek Nursing and Rehabilitation Center

Inspectors wroteBased on record review, and interviews with staff and Physician, the facility failed to ensure a system was in place to check the accuracy of resident care equipment used to check blood pressure readings and temperature readings. Additionally, per interview with a Nurse Practitioner and a Physician, a facility's glucometer reading was difficult to reconcile with other known details regarding a resident's condition and treatment. This affected 1 of 3 sampled residents reviewed for change in condition and had the capability to affect all residents (Resident #2).

Inspectors wroteBased on record review, and interviews with staff, Physicians, and Nurse Practitioner, the facility staff failed to consult with the physician when a resident's fingerstick blood sugar result was 509. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). This was for 1 of 3 residents reviewed for notification to the physician (Resident # 2).

Inspectors wroteBased on record review, and interviews with staff, Responsible Party, Physician, and Nurse Practitioner, for a newly admitted resident whose insulin orders had recently been changed before facility admission in conjunction with the resident being changed from an oral diet to an enteral feeding (the delivery of nutrition directly into the gastrointestinal tract when a person cannot eat enough by mouth), the facility failed to recheck the resident's finger stick blood sugar result of 509 within the timeframe the resident's prescribed insulin typically worked to cover elevated blood sugar levels. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). [...]

Inspectors wroteBased on record review, and interviews with staff, Pharmacists, and Medical Director the facility failed to 1) ensure they obtained medications from the pharmacy or the facility's back up supply for administration for a newly admitted resident and 2) upon admission clarify an order which directed a 12 hour extended release medication was to be administered via way of a gastrostomy tube so that the pharmacy would dispense an alternate form of the medication that was appropriate to be administered via gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach). This was for 1 of 1 resident whose medications were reviewed (Resident # 2).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the medical record was complete regarding a change in condition for 1 of 3 residents reviewed for medical record accuracy (Resident #2).

Inspectors wroteBased on observations and staff interviews the facility failed to label or date food items stored in 1 of 1 walk-in cooler. This had the potential to affect food served to residents.

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to clean and maintain privacy curtains, oxygen concentrators, and walls in resident rooms for 3 of 44 resident rooms (Resident #18, Resident #79, and Resident #160) on 2 of 11 halls (200 and 300 Halls) observed for environment.

Inspectors wroteBased on observations, record review, and interviews with staff and the Medical Director, the facility failed to notify a nurse after an assisted fall and not move the resident after a fall before a licensed nurse's assessment. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out, and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. NA #1 did not report the assisted fall to a nurse and did not get a nurse to assess the resident before transferring to the wheelchair. [...]

Inspectors wroteBased on observations, record review, and interviews with staff and Medical Director, the facility failed to follow the Resident Care Guide and use a mechanical lift prior to the transfer of a resident (Resident #1). On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) did not see any mechanical lifts immediately available and entered Resident #1's room at approximately 2:45 PM. Despite knowing that Resident #1 required a mechanical lift for all transfers, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. [...]

Inspectors wroteBased on record review, staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a significant change in a resident's condition that included transport and admission to the hospital for 1 of 4 residents reviewed for notification of change (Resident #1).

Inspectors wroteBased on observations and staff interviews, the facility failed to replace a damaged bed mattress for 1 of 32 residents reviewed for environment (Resident #9).

Inspectors wroteBased on record review, and resident, staff, pharmacist and physician interviews, the facility failed to protect a resident's right to be free from the misappropriation of medication for 2 of 2 residents (Resident #116, Resident #163) reviewed for misappropriation of resident property.

Inspectors wroteBased on record review and staff interview the facility failed to develop a comprehensive care plan in the area of fall risk for 1 of 3 residents reviewed for accidents (Resident #81).

Inspectors wroteBased on record review, and staff, physician, and pharmacist interviews, the facility failed to ensure two residents received Ozempic subcutaneous injections as ordered for 2 of 7 residents reviewed for medication errors. (Resident #116 and Resident #163)

Inspectors wroteBased on observation, record review, and staff and Nurse Practitioner (NP) #1 interview the facility failed to follow professional standards of practice and infection prevention measures when a nurse failed to perform hand hygiene between the removal of soiled gloves and the application of sterile gloves, when Nurse #4 touched the outside of the tracheostomy packaging with sterile gloves and did not change them and when she dropped a sterile q-tip onto the residents nightgown and proceeded to use it to clean the tracheostomy site. She further failed to keep sterile technique when she touched the new, sterile, inner cannula with contaminated sterile gloves that had touched the outside of the tracheostomy tray. This was for 1 of 1 resident (Resident #85) reviewed for respiratory care.

Inspectors wroteBased on observation and staff interview the facility failed to ensure a Nurse was competent to provide tracheostomy care for 1 of 1 resident reviewed for tracheostomy (surgically created airway in the front of the neck) care (Resident #85).

Inspectors wroteBased on record review, and resident, staff, physician, physician assistant, and pharmacist interviews the facility failed to ensure ear drop medication was administered via the correct route into the ears and not into the eyes. This was for 1 of 7 residents (Resident #2) reviewed for medication errors.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393).

Inspectors wroteBased on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Medicaid/Medicare Coverage Liability Notice (F582) originally cited on 7/29/21 during a recertification and complaint investigation survey and subsequently recited on 11/30/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to ensure that smoking materials were secured by staff for three of three sampled residents observed for accidents (Resident #101, Resident #107, and Resident #119).

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain clean dishes that were ready for use and failed to dry small rectangular bowls prior to stacking on the tray line ready for use during 1 of 2 kitchen observations. This practice had the potential to affect food served to all residents.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to maintain walls and resident beds in good repair for 6 of 6 resident rooms (Room # 104, 105, 106, 111, 301 and 602) reviewed for provision of a safe, clean, homelike environment.

Inspectors wroteBased on record review, observation, and staff interviews the facility failed to perform incontinence care on 1 of 1 resident (Resident #24) who was dependent on staff for incontinence care, in a manner to prevent the likelihood of an infection. Resident #24 was observed for Activities of Daily Living (ADL) care.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to place palm guards on the left and right hands for 1 of 1 resident (Resident #3) reviewed for range of motion.