Willow Park Health Care Center

In the surveyor’s words

From the most serious findings on record at Willow Park Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jan 22, 2026

  On 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure a comprehensive care plan was developed for Resident #9 to prevent an elopement on 07/27/25. Resident #9's cognition was severely impaired with a BIMS score of 2. Resident #9 had four elopement assessments which identified Resident #9 as a high risk for elopement. Resident #9 had several exit seeking attempts and elopements during a three-month period. After each elopement or attempted elopement, the resident was placed on one-on-one supervision. Resident #9's care plan was not updated with one-on-one supervision, and there was no documentation of one-on-one supervision was ongoing to prevent elopement. […]

• Immediate jeopardy, isolatedF689Jan 22, 2026

  On 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure Resident #9 had adequate supervision to prevent elopements on 07/11/25, 07/27/25, 09/04/25, and 09/30/25.Resident #9's cognition was severely impaired with a diagnosis of dementia. Resident #9 had three elopement assessments that placed them at high risk for elopement. Resident #9 had two episodes of exit seeking where staff redirected them and brought them back into the facility, and four additional elopements where staff were not aware the resident was gone from the facility. The facility failed to ensure adequate supervision to protect Resident #9 from elopement. […]

• Immediate jeopardy, isolatedF689Oct 7, 2024

  On 10/03/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #38, who had been assessed to require supervision and a smoking apron when smoking, was provided adequate supervision. A care plan intervention, updated 01/31/24, documented Resident #38 required staff supervision with smoking and the use of a smoking apron. A smoking assessment, dated 02/15/24, documented Resident #38 was safe for smoking with supervision and use of a smoking apron. An incident report, dated 04/19/24, documented an unwitnessed incident. The report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. […]

• Actual harm, patternF686Jun 27, 2022

  Based on record review, observation, and interview, the facility failed to ensure a resident received necessary treatment and services, for a pressure ulcer, for one (#1) of eight residents sampled for wound care. The facility failed to ensure: a. weekly skin assessments were completed, and; b. the resident was seen by the wound care physician for follow-up wound care. The Administrator reported seven residents with wounds who resided in the facility. Findings: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care (WC) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the resident had two wounds, including a shear wound of the left buttock measuring 11 cm x 9 x 0.2. […]

• Actual harm, patternF690Jun 27, 2022

  Based on record review and interview, the facility failed to ensure a resident with a suprapubic catheter was assessed, monitored, and interventions implemented in a timely manner, to prevent a urinary tract infection, for one (#1) of one resident sampled for catheter care. The administrator reported they had no other residents with a suprapubic catheter. Findings: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 10/26/21, read in parts .Focus, The resident has Indwelling Suprapubic Catheter. Goal, The resident will show no s/sx of Urinary infection through review date 04/04/22. […]