Willowcreek Rehab and Nursing

In the surveyor’s words

From the most serious findings on record at Willowcreek Rehab and Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 27, 2025

  Based on observations, interviews, and record review, the facility failed to maintain hot water below 110 F for 5 of 8 (Resident #60's sink, RM17 E sink, East Hall shower room sink, Resident #168, Resident #167, and Resident # 14's shared sink and RM 24 E sink) bathroom reviewed for water temperature. 1. The temperature of sink in RM 17E was 150 F. 2. The temperature of the East Hall Shower Room Resident 150 F. 3. The temperature of Resident #168, Resident #167, and Resident #14's shared sink was 140 F. 4. The temperature of Resident #60's sink was 136.4 F. 5. The temperature of sink in RM 24E was 125.2 F. 6. The shower water temperature fluctuated, becoming hotter during use for Resident #23 and Resident #1 An Immediate Jeopardy (IJ) situation was identified on 02/25/2025. […]

• No harm, potential for more than minimal, patternF550May 6, 2026

  Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and treat residents with respect and dignity for 3 of 12 (Residents # 62, Resident # 45, and Resident # 22 ) residents reviewed for dignity.The facility failed to prevent CNA E from standing over Resident# 62, Resident # 45, and Resident # 22 while assisting residents with eating their meal in the dining area.The facility failed to prevent CNA E from referring to Resident# 62, Resident # 45, and Resident # 22 who needed assistance with meals, as feeders.These failures could affect residents that… […]

• No harm, potential for more than minimal, patternF583May 6, 2026

  Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights.The facility failed to ensure staff distributed mail received on Saturdays to the residents. This failure could result in residents not receiving mail in a timely manner and a diminished quality of life.Findings included:During a confidential group interview on an undisclosed date and time, 5 of 5 members in the group stated they did not receive mail on Saturdays because the girls in the offices did not work on… […]

• No harm, potential for more than minimal, patternF584May 6, 2026

  Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a sanitary, and comfortable environment for 5 of 20 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], 104 and the East Conference Room) rooms observed for environmental conditions. The facility failed to ensure rooms 101,102, 103, 104 and the East side Conference Room sinks had hot water. These failures could place residents at risk for diminished quality of life, discomfort, and safety. Findings included: During an observation on 05/05/2026 at 12:16 p.m., East Side room [ROOM NUMBER] the water temperature in the sink with shared toilet room with room [ROOM NUMBER] hot water felt cold. […]

• No harm, potential for more than minimal, patternF759May 6, 2026

  Based on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 3 (Resident #10, Resident # 20 and Resident #25) of 5 residents reviewed for medication administration. The facility failed to ensure the medication error rate (11.5%) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Findings included: Resident #10 Record review Resident #10's face sheet dated 5/6/26 revealed a [AGE] year-old female with an admission date of 12/12/2024. She had an active diagnosis of Dysphagia (difficulty swallowing) following cerebral infarct. […]