Willow Crossing Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Willow Crossing Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident was free of physical and mental abuse by a staff member purposely and forcefully causing a resident to fall from the wheelchair onto the floor. This resulted in the staff member leaving the resident lying on the floor with no assistance, she walked away from the resident going into other resident rooms, while another resident was maneuvering their wheelchair around the resident, and the staff member failed to provide accurate details related to the fall for assessment and follow-up care for 1 of 6 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B. […]

• No harm, potential for more than minimal, patternF684Mar 11, 2026

  Based on record and interview, the facility failed to follow physician's orders related to hold parameters and obtaining vital signs for cardiac medications for 7 of 21 residents reviewed for quality of care. (Residents 44, 62, 30, 10, 3, 8, and 104) Findings include:1.The clinical record for resident 44 was reviewed on 03/10/2026 at 10:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/01/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, hypertension. An open-ended physician's order, with a start date of 12/22/2025, indicated the resident was to be given midodrine 10 milligrams (mg) twice a day for orthostatic hypertension. […]

• No harm, potential for more than minimal, patternF761Apr 19, 2024

  Based on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed and for 6 of 15 resident medications reviewed. (Residents 41, 88, 36, 91, 23, and 13) Findings include: 1. During an observation on 04/14/24 at 9:53 A.M., the back 200 Hall medication cart had the following residents' controlled medications preset for the noon medication pass: - Resident 41's Oxycodone 7.5/325 mg (milligrams) and lorazepam 1 mg, - Resident 88's hydrocodone-acetaminophen 7.5-325 mg, - Resident 36's Lyrica 50 mg and hydrocodone-acetaminophen 7.5-325 mg, - Resident 91's tramadol 50 mg, and - Resident 23's hydrocodone-acetaminophen 10-325 mg. […]

• No harm, potential for more than minimal, patternF812Apr 19, 2024

  Based on observation and interview, the facility failed to ensure food was served in a sanitary manner for 2 of 4 dining observations and 4 of 5 staff observations. (CNA 3, CNA 17, QMA 16, and CNA 5) Findings include: 1. During a dining observation in the Memory Care Unit on 04/14/24 the following occurred: - At 12:20 P.M., CNA (Certified Nurse Aide) 3 delivered Resident 70's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the clear plastic package with her bare hand, placed the package on the table, and placed the roll on top of the package. - At 12:23 P.M., CNA 17 delivered Resident 159's meal. She removed the plate and cups from the tray and placed them on the table. […]

• No harm, potential for more than minimal, patternF887Oct 26, 2023

  Based on record review and interview, the facility failed to provide COVID-19 booster immunizations for 8 of 10 residents reviewed for immunizations (Resident F, G, L, M, C, D, E, and H) Findings include: 1. The clinical record for Resident F was reviewed on 10/25/23 at 10:30 A.M. An Admission MDS (Minimum Data Set) assessment, dated 10/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, cancer, anemia, heart failure, hypertension, diabetes, anxiety, and depression. The resident's Admission Packet, dated 10/03/23, indicated the resident requested the facility would ensure the resident received the COVID-19 booster as soon as it was available. The form was signed by the resident. […]