Willow Creek Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Aug 17, 2021

  Based on interviews with staff, pharmacist, physician, and review of facility, Emergency Medical Service (EMS) and hospital records, the facility failed to recognize that blood sugar monitoring was indicated for a resident whose medication for diabetes was increased at a time when July blood sugars and A1C were within normal limits. The facility failed to check the blood sugar on a resident who was diabetic with altered mental status 1 of 1 resident (Resident #1). On August 4, 2021, Resident #1 was found to have altered mental status. Once EMS arrived, fingerstick was performed and it was 27. Resident #1 was started on an intravenous infusion of glucose and taken to the emergency room . […]

• Actual harm, isolatedF684Feb 13, 2026

  Based on observations, record review, and interviews with staff and the Medical Director, the facility failed to notify a nurse after an assisted fall and not move the resident after a fall before a licensed nurse's assessment. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out, and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. […]

• Actual harm, isolatedF689Feb 13, 2026

  Based on observations, record review, and interviews with staff and Medical Director, the facility failed to follow the Resident Care Guide and use a mechanical lift prior to the transfer of a resident (Resident #1). On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) did not see any mechanical lifts immediately available and entered Resident #1's room at approximately 2:45 PM. Despite knowing that Resident #1 required a mechanical lift for all transfers, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. […]

• No harm, potential for more than minimal, widespreadF908Jun 11, 2026

  Based on record review, and interviews with staff and Physician, the facility failed to ensure a system was in place to check the accuracy of resident care equipment used to check blood pressure readings and temperature readings. Additionally, per interview with a Nurse Practitioner and a Physician, a facility's glucometer reading was difficult to reconcile with other known details regarding a resident's condition and treatment. This affected 1 of 3 sampled residents reviewed for change in condition and had the capability to affect all residents (Resident #2).The findings included:Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26). […]

• No harm, potential for more than minimal, widespreadF582Nov 30, 2023

  Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393). Findings included: a. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's record indicated the SNF ABN dated 11/8/23 had no estimated out of pocket cost for care documented on the form. Resident #70 remained in the facility with benefit days remaining. b. Resident #134 was admitted to the facility on [DATE]. Review of Resident #134's record indicated the SNF ABN dated 11/22/23 had no estimated out of pocket cost for care documented on the form. […]