Willow Knoll Post-Acute and Senior Living

In the surveyor’s words

From the most serious findings on record at Willow Knoll Post-Acute and Senior Living, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents who received food from the kitchen. The facility census was 53. Findings include: A facility policy titled, Food Receiving and Storage, revised November 2022, revealed a section titled Dry Food Storage, that specified, 4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated 'use by' date). Such foods are rotated using a 'first in-first out' system. The policy continued, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date). […]

• No harm, potential for more than minimal, widespreadF880Aug 24, 2021

  Based on observation, medical record review, staff interviews, policy review and review of the Centers for Disease Control (CDC) recommendations, the facility failed to ensure staff members donned appropriate personal protective equipment (PPE) when caring/entering a resident's room on quarantine to prevent the potential spread of Coronavirus (COVID-19). This affected three (#13,#30, and #34) of three residents observed in quarantine. The facility identified 32 residents currently under quarantine. This had the potential to affect all residents. The facility census was 44. Findings include: 1. Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF563Jul 9, 2021

  Based on observation, visitation signage, interview, and review of the Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure residents were allowed visitation. This affected all of the residents who resided in the facility. The census was 45. Findings include: Review of the coronavirus website for the county positivity rate for Covid-19 revealed as of 06/22/21, the positivity rate in [NAME] county was 1.9%. Review of the list of vaccinated residents in the facility, dated 06/28/21, revealed 22 of 45 residents, or 48 percent, had been vaccinated. Observation of signs on the front door to the entrance of the facility on 06/28/21 at 9:00 A.M. revealed visitation was not allowed unless it was scheduled through the facility. […]

• No harm, potential for more than minimal, widespreadF725Feb 18, 2021

  Based on medical record review, staff and resident interview, observation, and facility policy review, the facility failed to ensure there was enough staff to provide activities of daily living including bathing and brushing teeth to the residents. This affected three residents (#7, #19 and #30) reviewed for staffing. This had the potential to affect all 45 residents residing in the facility. Findings included: 1. Medical record review for Resident #19 revealed an admitted d of 04/15/19. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/20 revealed Resident #19 was cognitively intact. Function status for bathing was one-person physical help. […]

• No harm, potential for more than minimal, widespreadF727Feb 18, 2021

  Based on review of timecard punch detail and staff interview the facility failed to ensure the Director of Nursing (DON) worked full time hours of at least 35 hours per week. They also failed to ensure a Registered Nurse (RN) worked eights hours a day, seven days a week. This had the potential to affect all the residents. The census was 45. Findings include: Review of timecard punch detail for Interim Director of Nursing (IDON) #112 from 08/07/21 through 11/10/21 revealed the week of 08/30/20 through 09/05/20 she worked 30 hours and 39 minutes. The week of 09/13/20 through 09/19/20 she worked 38 hours and 8 minutes. The week of 10/11/20 through 10/17/20 she worked 33 hours and 10 minutes. The week of 10/25/20 through 10/31/20 she worked 29 hours and 51 minutes. […]