Willow Springs Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Willow Springs Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 22, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident's smoking location was away from a high traffic thoroughfare, dry grassy area, and had a receptacle for disposing of lit cigarettes and ashes for 1 of 1 sampled resident (Resident 30) reviewed for smoking This failure placed all residents a risk for avoidable accidents, injuries, and the potential risk of fire. On 07/17/2023 At 2:10 PM, the facility was notified of an immediate jeopardy (IJ) at CFR 483.25 (d)(1)(2) F689, related to the facility's failure to ensure the resident had a safe smoking environment, and all residents remained free of fire risks. […]

• Actual harm, isolatedF686Jul 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer development for 1 of 2 residents (1) reviewed for facility acquired pressure ulcers. The facility failed to complete a thorough admission assessment of Resident 1's skin, re-assess on a weekly basis per the resident's care plan, and act to treat and prevent further development after first identified on 05/19/2022. This failure caused harm to Resident 1 when they developed a preventable Stage 3 pressure ulcer that required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . […]

• Actual harm, isolatedF689Mar 16, 2021

  Based on interview, and record review, the facility failed to ensure residents with falls were thoroughly investigated to determine the circumstances of resident accidents and failed to find root cause analysis to minimize injury, avoid reoccurrence of falls, and to develop and implement measures to prevent further falls with injury, for two of three Residents (4 and 5) reviewed for multiple falls. Failure to thoroughly investigate falls and determine the root cause of falls, and re-evaluate fall risks and interventions, resulted in a fall with a large bruised lump to Resident 4's head and a new compression fracture to Resident 4's back, and a fall for Resident 5 resulted in a fracture of the left hip and required surgical intervention. […]

• Actual harm, isolatedF760Mar 16, 2021

  Based on interview and record review, the facility failed to ensure one of three sampled residents (1) reviewed for medication errors, was free from a significant medication error. Failure to ensure the correct narcotic [MEDICATION(S)] (Tramadol - a narcotic [MEDICATION(S)]) was administered to the right resident (Resident 1), resulted in harm to Resident 1, who was given the wrong narcotic [MEDICATION(S)] medication ([MEDICATION(S)] - an opioid pain medication) that required the administration of [MEDICATION(S)] (a nasal spray used for known or suspected signs and symptoms of narcotic overdose). Findings included . […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2025

  Based on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) that did not have the proper labels and dates for food safety tracking, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1of 1 kitchen reviewed and 3) ensure the dishwasher sanitizer concentration was effective for sanitation for 1of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses. […]