Willow Park Rehabilitation Health Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's call light was within reach on 05/20/26. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 5 (Resident #6, Resident #11, Resident #57, Resident #84, and Resident #85) of 13 residents reviewed for abuse. The facility failed to ensure the safety of Resident #84 on 12/3/25 when Resident #11 hit him in the chest causing the resident to fall and hit the ground hard resulting in Resident #84 being sent out to the hospital for evaluation of injuries. The facility failed to ensure the safety of Resident #85 on 11/19/25 when Resident #11 punched him in the face. The facility failed to ensure the safety of Resident #6 on 11/22/25 when Resident #11 pushed him to the ground. The facility failed to ensure the safety of Resident #57 on 12/9/25 when Resident #11 hit him on the arm. An Immediate Jeopardy (IJ) was identified on 12/16/2025. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 2 of 3 computers reviewed for privacy and confidentiality. On 12/18/2025 LVN O left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. On 12/18/2025 LPN K left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. On 12/19/2025 LVN O left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. These failures could place residents at risk of having their private information changed, viewed, and not kept secure.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Residents #9) of 6 residents reviewed for resident rights. The facility failed to obtain an informed consent for the use of Ativan (an antianxiety medication) used for Resident #9. This failure could place residents at risk of receiving medications without prior consent and without the option to choose alternative treatment or decline based on awareness of risk and benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #65) reviewed for resident rights. The facility failed to ensure Residents #65's call light was within reach on 12/16/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #3, Resident #6, and Resident #84) who were reviewed for accuracy of assessments. 1. Resident #3's SCSA MDS did not indicate he was admitted to hospice in all the necessary sections. 2. Resident #6's most recent comprehensive MDS was coded as having a catheter, but Resident #6 did not have an order for a catheter, nor was he observed with one. 3. Resident #84's most recent comprehensive MDS was coded as resident having used insulin in the last 7 days, when medication review, orders, and interviews revealed that Resident #84 did not use insulin. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #73) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #73. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major Depressive Disorder) was present upon Resident #73's admission date on 01/17/2025. This failure could place residents at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needsFindings included: Record review of Resident #73's face sheet, dated 12/19/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #73 had diagnoses which included: [...]

Inspectors wroteBased on interviews , and record review the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #6) reviewed for comprehensive care plans. The facility failed to care plan Resident #6's PTSD and/or triggers. This failure could place residents at risk of their needs going unmet.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 6 residents (Resident #32) reviewed for quality of life. The facility failed to ensure Resident #32's nails were cleaned and trimmed. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #36) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #36 did not leave the facility without nursing staff being aware and he was found by state survey staff in front of a store approximately 100 yards from the facility. 2. The facility failed to follow their elopement policy when informed of a missing resident. These failures placed residents at risk of elopement, falls, or other accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #6) of 6 residents reviewed for trauma-informed care. The facility failed to ensure Resident #6 had a trauma assessment completed upon admission to the facility that identified possible triggers when Resident #6 admitted with a diagnosis of PTSD. This failure could place residents at an increased risk of psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident #13) whose records were reviewed for behavioral health services. The facility failed to provide psychological services for Resident #13 to treat her symptoms of depression noted by her recent behaviors and MDS assessment. This deficient practice could place residents with documented signs of depression at risk of increased decline in the psychosocial well-being and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: The facility's dietary staff failed to discard an outdated item in the walk-in freezer. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents reviewed for infection control (Resident #5, and Resident #70). 1) LVN C did not wash her hands when removing soiled gloves, prior to applying clean gloves on 12/17/2025 at 10:01 a.m. for Resident #5's wound care observation. 2) CNA M and CNA N failed to clean their hands prior to the start of and after changing gloves when moving from a dirty to clean site while performing peri care for Resident #70 on 12/17/2025 at 11:04 a.m. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care. The facility failed to activate 911 emergency services response on 06/13/2025 for Resident #1 when he had a choking episode while eating resulting in his death. An IJ (Immediate Jeopardy) was identified on 07/08/2025. The IJ template was provided to the facility on [DATE] at 5:12 PM. While the IJ was removed on 07/10/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of physical harm, pain, mental anguish, or death.

Inspectors wroteBased on interviews, and record review the facility failed to ensure all alleged violations involving neglect were reported to the State Survey Agency in a timely manner for 1 of 5 (Resident #) residents reviewed for abuse and neglect. The facility failed to report an incident to the state survey agency when Resident #1 had a choking episode while eating, resulting in death, after staff failed to activate 911 emergency response on 06/13/2025. The failure could place residents at risk of physical harm, pain, mental anguish, or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from abuse when CNA A placed her hand over Resident #1's mouth to keep her from talking while she provided care to the resident. This failure could place residents at risk of experiencing and enduring abuse by facility staff causing a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were complete and accurately documented for one of six residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's medical chart contained incident reports, assessments , and nursing progress notes of an incident dated 10/03/2024 or 10/04/2024. This deficient practice could place residents at risks of errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 residents (Resident #82) reviewed for cardio-pulmonary resuscitation. LVN B failed to initiate CPR when she found Resident #82, who was full code status, unresponsive and not breathing. Resident #82 was declared deceased . An Immediate Jeopardy (IJ) situation was identified on 09/26/24 at 4:42 PM. While the IJ was removed on 09/27/24 at 12:57 PM, the facility remained out of compliance at a scope of isolated identified as no actual harm with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. The facility failed to seal food and dispose of spoiled food. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/24/24 beginning at 9:35 AM revealed: - 2 cantaloupes with fuzzy white and black spots; - 1 white onion with fuzzy white spots; - 1 bag of shredded carrots open and exposed to air; - 1 bag of shredded cheese open and exposed to air; - 1 red onion and small potato on the floor; and - meat thawing in a container with blood dripping on the floor. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the discharge summary was document in Resident #81's medical record. Resident #81 did not have a discharge summary or documentation of the discharge on [DATE]. This failure could put residents at risk of not getting the necessary care and services with the possibility of the resident returning to the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet residents' medical needs for one (Resident #68) of six residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #68's diagnosis of diabetes. This failure could place residents at risk of receiving inadequate individualized care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities identified by the pharmacist were reviewed by the attending physician and the attending physician documented in the resident's medical record their rationale when there was to be no change in the medications for one (Resident #68) of five residents reviewed for medication regimen review. The facility failed to ensure the physician documented a clinical rationale for making no changes to Resident #68's medications after the Pharmacist Consultant had recommended gradual dose reductions for psychoactive medications. This failure could place residents at risk for prolonged use of an unnecessary medication, dependence on unnecessary medications, possible adverse side effects and consequences, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for four (Resident #27, #30, #33, and #215, ) of 44 residents observed for wheelchairs. The facility failed to properly maintain wheelchairs for Residents #27, #30, #33, and #215. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. This failure could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Nurse Staffing Information was posted daily for one of one building. The facility did not post and maintain the required staffing information from July 21, 2023, to July 24, 2023. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections.