Willow Terrace

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 7, 2025

  Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. Resident R1 was unable to be located for over six hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. […]

• Actual harm, isolatedF600Mar 19, 2026

  Based on review of clinical records, facility documents, and interview with staff and residents, it was determined the facility failed to ensure Resident R1 was free from physical abuse. This failure resulted in actual harm to Resident R1 who was grabbed by a facility's employee by the collar, held in a choking position and placed (his/her) hand on the resident's face. The employee's hands had to be pried away from Resident R1's. A reasonable person would determine that a staff member holding a resident with a diagnosis of major depression and heart failure in a chocking hold caused actual harm, placing Resident R1 at risk for psychological trauma or one of five residents reviewed. […]

• Actual harm, isolatedF600Aug 29, 2024

  Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from abuse, which resulted in actual harm to Resident R2 who was pushed by a nursing staff, fell to the floor and sustained an acute fracture of the distal radial metaphysis for one of eight residents reviewed. (Resident R2) Findings include: Review of facility policy, 'Abuse policy- Prevention and Management', dated September 8, 2022, reviewed on august 2024, revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. […]

• No harm, potential for more than minimal, patternF584Jan 31, 2025

  Based on observations, review of facility records, interviews with resident and staff, it was determined that the facility failed to ensure comfortable and safe temperature levels. Facilities failed to maintain a temperature range of 71 to 81 F for four of four resident rooms. (301, 302, 311, 328) Findings Include: Interview with Resident R169 on January 28, 2025, at 11:00 a.m. with Maintenance Director, Employee E9 stated the room temperature was too high, and she was suffocating in the room. She stated she had COPD and would like the room temperature at 72-degree Fahrenheit. Interview with Resident R134 on January 28, 2025, at 11:35 a.m. it was too hot for her, and she needed fan to make her comfortable. Resident stated it's been a month since the facility had the temperature issue. […]

• No harm, potential for more than minimal, patternF684Sep 11, 2024

  Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to obtain and follow physician orders related to medications, wound care and dietary recommendations for three of five residents reviewed (Residents R1, R2 and R3). Findings include: Review of facility policy, Medication Management - Unavailable Meds dated April 22, 2024, revealed, If a medication shortage is noted during normal pharmacy hours, a licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order . […]