Willow Creek Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF697Jun 30, 2023

  Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed resident's severe pain for 1 of 1 sampled resident (#18) reviewed for pain management. This resulted in Resident 18 having unrelieved, unmanageable pain and treatment at the hospital Emergency Department. Findings include: Resident 18 admitted to the facility in 4/2023 with diagnoses including chronic pain and osteoarthritis. A 5/10/23 Behavioral Symptoms and Pain CAA revealed Resident 18 had episodes of cursing, yelling and became agitated at staff notably when she/he had extreme pain while pending hip surgery. When Resident 18's pain was managed she/he was in a pleasant mood. […]

• Actual harm, isolatedF686May 6, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 2 of 2 sampled residents (#s 4 and 8) reviewed for pressure ulcers. This resulted in multiple avoidable Stage 2 pressure ulcers for Resident 8. This placed other residents at risk for worsening pressure ulcers. Findings include: 1. Resident 8 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/22 Admission MDS Pressure Ulcer CAA indicated Resident 8 had a pressure relief mattress, had no current skin breakdown and was to be care planned for risk of skin breakdown. Resident 8's Care Plan did not identify any pressure ulcers or interventions prior to 5/4/22. […]

• Actual harm, isolatedF692May 6, 2022

  Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain acceptable parameters of nutritional status and ensure residents received a therapeutic diet and nutritional supplements as ordered for 2 of 4 sampled residents (#s 4 and 14) reviewed for nutrition. This resulted in Resident 14 and Resident 4 experiencing a severe weight loss. This placed other residents at risk for weight loss. Findings include: The 2001 Facility Nutrition Program Policy indicated: 1. Direct care staff, assisted by the facility's Clinical Dietitian, will evaluate each individual's physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. […]

• Actual harm, isolatedF600Mar 15, 2021

  Based on interview and record review it was determined the facility failed to ensure residents were free from neglect related to a failure to provide necessary goods and services to prevent accidents for 1 of 3 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a right femur fracture, experiencing increased pain, and placed the resident at risk for further accidents. Findings include: A public complaint was received on 9/24/20, which indicated Resident 1 slipped out of her/his shower chair due to the facility placing garbage bags on the chair and the resident hit her/his head and right knee sustaining fractures. The complaint indicated Resident 1 still had not seen a doctor and was waiting for a call from the surgeon. […]

• No harm, potential for more than minimal, widespreadF812Oct 9, 2024

  Based on interview and record review it was determined the facility failed to monitor and maintain refrigerator and dishwasher temperatures for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for food borne illnesses. Findings include: Review of the facility's kitchen Equipment Temp Log on 10/8/24 for the refrigerator, freezer, dishwasher and dish rinse revealed the following: - The log included entries from 9/17/24 through 9/30/24. There was no record of temperatures taken prior to 9/17/24. - The log included entries from 10/1/24 through 10/4/24. On 10/5/24 the refrigerator and freezer temperature was documented but the dishwasher temperature was not documented. There were no documented temperatures after 10/5/24. […]