Willow Creek Lodge

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 13, 2024

  Based on observation, interview, and record review, the facility failed to maintain correct chemical concentration , based on periodic testing, at least once per shift during the dishwasher's wash cycle in one of one kitchen. The facility failed to test and maintain proper concentration level of sanitizer solution during the dishwasher's wash cycle. This failure could affect all residents by placing them at risk for food-born illness. Findings included: Observation of the kitchen on 06/11/2024 at 9:08 am revealed the facility's only dishwasher in use at the time, was a low-temp dishwasher. Staff A was observed performing a strip test after a load of dishes had been washed. The strip did not change color after 5 attempts; indicating lower than minimum PPM levels of sanitizer solution. […]

• No harm, potential for more than minimal, widespreadF922Mar 24, 2023

  Based on observations, interviews, and records reviewed, the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply for 1 of 1 facility. -The facility's emergency water supply consisted of 225 gallons (45, 5-gallon jugs) of water on hand for a census of 76 residents and 104 employees stored in a shed behind the building. This failure could place residents at serious risk for complications from dehydration and sanitation. Findings included: Observation of the emergency water supply on 03/23/2023 at 4:15 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2022

  Based 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 for 1 of 1 kitchen reviewed for kitchen sanitation, in that: The facility failed to ensure food items were stored under appropriate condition in the freezer - items in the freezer were not frozen, the freezer temperature was 40 degree Fahrenheit. This failure could place residents who eat food made in the kitchen at risk of foodborne illnesses. […]

• No harm, potential for more than minimal, patternF641Jul 17, 2025

  Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 5 residents (Resident #2, Resident #67, and Resident #83) reviewed for accuracy of assessments .- The facility failed to accurately assess Resident #2's use of antipsychotics on her Quarterly MDS dated [DATE].- The facility failed to accurately assess Resident #67's dialysis status and use of antiplatelets on her Admissions MDS dated [DATE].- The facility failed to accurately assess Resident #83's hospice status on her Quarterly MDS dated [DATE].Findings include:Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility… […]

• No harm, potential for more than minimal, patternF656Jul 17, 2025

  Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 Residents (Resident #2 and Resident #67) reviewed for care plans.- The facility failed to include Resident #2's diagnosis of MDD in her care plan.- The facilitate failed to include Resident #67's diagnosis of hypotension (low blood pressure), CAD (buildup of fats & cholesterol on the walls of blood vessel), hyperlipidemia (high cholesterol) , COPD (disease that makes… […]