Willow Creek Health Care

In the surveyor’s words

From the most serious findings on record at Willow Creek Health Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 17, 2026

  Based on observation, interview, and facility policy review, the facility failed to ensure food was served at safe temperatures for 50 of 51 residents who received meals from the dietary department. Specifically, the facility did not maintain hot food holding temperatures at 135 degrees Fahrenheit ( F) or above during meal service.Findings included: A facility policy titled, Food Holding and Service, revised 06/01/2019, revealed Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US [United States] Food Codes and HACCP [Hazard Analysis and Critical Control Points] guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less. […]

• No harm, potential for more than minimal, widespreadF880Jul 17, 2026

  Based on observation, interview, and facility policy review, the facility failed to develop, implement, and maintain a process for monitoring the facility's water system for potential waterborne pathogens. Additionally, nursing assistant students (Students) and dietary staff failed to implement hand hygiene when plating food, serving plates, and assisting residents with meals for 3 of 3 meal service observations.Findings included: 1. A facility policy titled, Infection Prevention and Control Program, revised 07/2024, specified, Water Management: Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. The Maintenance Director oversees the facility's water system. […]

• No harm, potential for more than minimal, patternF657Nov 9, 2022

  Based on record review, observations and interviews, the facility failed to review/revise/implement the care plans for three (#15, 30 and #45) of eight sampled residents reviewed for care plans. This affected: The Resident Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APsychological Services Progress Note[s], dated 08/11/22, 08/18/22, 09/01/22, 09/08/22, and 09/29/22, read in parts, .Current Risk Factors .Suicidal/Self Injury: Ideation . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF684Nov 9, 2022

  Based on record reviews, observations and interviews, the facility failed to a. re-assess/monitor and intervene for one (#26) of one sampled resident with a change of condition; and b. follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Residents Census and Condition of Residents, dated 11/03/22, documented the facility census was 49. Findings: 1. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 10/08/22 at 3:00 p.m., read in parts, .complaining of having the fuzzy-wuzzies .taking a shower and dropped his washcloth and bent over to pick it up when he had the 'fuzzy-wuzzies' .vital signs: 170/102, 60 .assisted to get into his wheelchair and taken to his room .still a little unsteady while getting into his wheelchair .was told to lie down… […]

• No harm, potential for more than minimal, patternF758Nov 9, 2022

  Based on record review, observation, and interview, the facility failed to ensure a PRN [CONDITION(S)] medications order was limited to 14 days for one (#26) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 27 residents received psychoactive medications. The Census was 49. Findings: Resident #26 had diagnoses to include major depressive disorder, and [CONDITION(S)]. A Care Plan, dated 02/07/18, read in parts, .[CONDITION(S)] drug use .Has interrupted Sleep patter r/t [CONDITION(S)] .[MEDICATION(S)] ([MEDICATION(S)]) 15 mg PO Q HR PRN . A physician order, dated 11/30/18, documented Resident #26 was to be administered [MEDICATION(S)] 15 mg every evening for [CONDITION(S)]. […]