Willow Creek Retirement Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 12, 2024

  Based on interviews, record review, and facility investigation review, the facility failed to provide adequate supervision to prevent an accidental coffee burn for one (1) of the four (4) sampled residents. Resident #1 Findings included: Record review of the Facility Investigation with completion date 9/06/24 revealed the facility reported the incident of coffee spill with burn injury of Resident #1 to the State Agency (SA) and appropriate agencies in accordance with state and federal guidelines initially on 9/03/24 with final report submitted on 9/06/24. […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices during resident care by failing to perform hand hygiene during incontinent care (Resident #66), failing to implement Enhanced Barrier Precautions during catheter care (Resident #13), and contaminating environmental surfaces with soiled gloves during wound care (Resident #36) for three (3) of four (4) care observations.Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 3/23/23, revealed, .It is the policy of this facility to.maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission… […]

• No harm, potential for more than minimal, widespreadF812Feb 23, 2023

  Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean ice machine for the residents as evidenced by white, red, and black residue build up on the inside and outside of the ice machine, observed on one (1) of five (5) kitchen tours. Findings include: Review of the facility policy titled, Cleaning Instructions Ice Maker and Dispenser, dated 9/04, revealed, Policy: Equipment shall be maintained in a clean and sanitary condition . Procedure: . The ice making system can be cleaned in place without disassembling the water system. The cleaning process should be performed at least every 6 months or more often if local water conditions dictate . […]

• No harm, potential for more than minimal, patternF740Jan 6, 2026

  Based on record review, interview and facility policy review the facility failed to provide necessary behavioral services by qualified staff to ensure residents' dignity, privacy, and safety and failed to promote mental and psychosocial well-being for five (5) of (5) residents. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5. Findings include:Record review of the Facility Policy titled, Dementia Care with an implementation date of 1/04/26 revealed, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being.4. […]

• No harm, potential for more than minimal, patternF880Nov 7, 2024

  Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and wound care for two (2) of (19) sampled residents. Residents #14 and #30 Findings Include: A review of the facility's policy titled Hand Hygiene, dated 06/12/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . […]