The Willows at Springhurst

In the surveyor’s words

From the most serious findings on record at The Willows at Springhurst, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 3, 2025

  Based on observation, interview and review of facility policy, the facility failed to prepare, store, and serve food under sanitary conditions for 51 of 52 residents who received food from the kitchen. The findings include: Review of the facility's Hair Restraint Policy' revised date 07/09/2025, revealed all dining service employees were required to wear hair restraints as required by the Federal Food Code, Hair Restraints 2-402.11. Review of the Federal Food Code dated 2009, revealed food employees shall wear hair restraints such as hats, hair covering or nets that are designed and worn to effectively keep their hair from contacting exposed food. Observation, on 09/16/2025 at 2:14 PM, revealed the Cook's hair net was not covering the side or back of her hair. […]

• No harm, potential for more than minimal, widespreadF812Sep 3, 2021

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed undated and opened containers of salad dressing, and in the freezer unopened vegan trays, and meat and cheese packages. Additional observation of the freezer revealed a container of strawberries covered with a gray substance. […]

• No harm, potential for more than minimal, patternF730Sep 3, 2021

  Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure performance reviews were completed every twelve (12) months, for six (6) of six (6) nurse aides personnel files reviewed. The findings include: Review of the facility's policy, Quarterly Wage Investment Timeline, undated, revealed employee eligibility for increases was dependent on disciplinary actions incurred resulting from performance and performance improvement plans, etc. Review of the facility's Skills Check-Off sheets revealed the facility evaluated employees on Hand Washing, and Guidelines for Donning and Doffing Personal Protective Equipment (PPE). The facility did not provide a policy specific to Nurse Aid performance evaluation. […]

• No harm, potential for more than minimal, isolatedF644Dec 3, 2025

  Based on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Pre-admission screening and resident review (PASRR) evaluation for 1 of 1 sampled resident (Resident (R) 5).The findings include: The facility did not provide a policy specific to PASRR evaluation. Review of Resident (R) 5's, Face Sheet revealed the facility originally admitted the resident on 07/01/2022 with the most recent re-admission date of 11/25/2024 with diagnoses including acute and chronic respiratory failure, bipolar disorder, dementia, major depressive disorder, generalized anxiety disorder, and paranoid personality disorder. […]

• No harm, potential for more than minimal, isolatedF760Dec 3, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free of any significant medication errors and that medications were received at the right time for 1 of 8 sampled residents (Resident (R) 6).The findings include: Review of the facility policy titled, Medication Administration Times Procedural Guidelines, revised 12/01/2021 and reviewed 12/17/2024 revealed guidelines for determination of medication administration times based on a resident's preference unless a specific time is designated by the attending physician. […]