Willow Creek Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF580Jan 5, 2026

  Based on interview and record review, the facility failed to ensure nursing staff immediately notified the physician for physical and mental health change of condition for one of three residents, Resident 1, when on 4/8/25 Registered Nurse (RN) 1 did not recognize the physical and mental health decline of Resident 1 brought to her attention by Resident 1's daughter who was at the bedside. RN 1 did not provide the necessary medical notification for the altered mental status of Resident 1, symptoms included inability to swallow medications which prompted RN 1 to perform an oral sweep with her fingers, Resident 1's inability to verbally respond, refused breakfast, lunch and dinner which were all changes to Resident 1's baseline condition. […]

• Actual harm, isolatedF686Sep 24, 2025

  Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice to prevent pressure ulcers (PU- a localized injury to the skin and underlying tissues) for one of four residents (Resident 1) when licensed nurses assessed Resident 1 upon admission on [DATE] and were aware of the Resident 1's high risk for pressure ulcers and did not implement effective interventions to prevent pressure ulcers such as changes for size, dimension, weekly description. […]

• Actual harm, isolatedF580May 7, 2025

  Based on observation , interview and record review, the facility failed to recognize and appropriately act on a change in condition for one of three sampled residents, Resident 1, when staff were provided a list of medications on Resident 1's admission on 1/30/25 that included insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) and did not inform the physician. Nursing staff were aware of the diagnosis of diabetes (a disease that occurs when sugar in the blood is too high) and did not closely monitor symptoms of hyperglycemia (high blood sugar), nausea and malaise (general feeling of discomfort) and did not inform the physician of high blood glucose (sugar) measurements. […]

• Actual harm, isolatedF580Jun 7, 2024

  Based on interview and record review, the facility failed to ensure the physician was notified for a change in condition for one of three residents (Resident 1) when on 5/14/24 Resident 1 was observed to have an acute change in mental status, an abrupt loss of in appetite, weakness, fatigue, and was difficult to arouse. CNA 4 communicated the changes of Resident 1 to the licensed nurse and the license nurse did not assess the resident, did not notify the physician and the Responsible Party (RP-a decisionmaker for the resident) regarding the change in condition. […]

• Actual harm, isolatedF656Mar 9, 2021

  Based on interview and record review, the facility failed to implement its fall risk care plan for one of three sampled residents (Resident 1), when Resident 1, who was assessed as being a high fall risk, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 1 getting out of bed unassisted on 12/22/20. Resident 1 sustained a fall and obtained a left upper leg posterior and left hip femoral neck (bone that connects the hip and the upper thigh bone) impaction fracture (broken bone in the hip) and experienced pain. Resident 1 required a six day hospitalization from [DATE] to 12/28/2020. […]