Willowcreek Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Willowcreek Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 4, 2021

  Based on interview and record review, the facility failed to provide protective oversight for three residents (#1, #3, and #2) out of a sample of 4 residents, with known substance abuse issues, by not ensuring the residents were safe from illegal drugs brought into the facility and used by residents. On [DATE], Resident #1 was sent to the hospital for [CONDITION(S)] (slow heart rate) and a change in cognition/orientation. At the hospital he/she tested positive for [MEDICATION(S)] (a powerful synthetic opioid) and opioids. On [DATE], Resident #3, had a change in condition and a drug screen was ordered, due to recent behavior and mental status change. […]

• Immediate jeopardy, patternF740May 4, 2021

  Based on interview and record review, the facility failed to provide necessary behavioral health care services for three residents, with known substance abuse problems, to address their drug use problems. On [DATE], Resident #1 was sent to the hospital for [CONDITION(S)] (slow heart rate) and a change in cognition/orientation. At the hospital, he/she tested positive for [MEDICATION(S)] (a powerful synthetic opioid) and opioids. On [DATE], Resident #3, had a change in condition and a drug screen was ordered, due to recent behavior and mental status change. On [DATE], he/she was suspected of a possible drug overdose, [MEDICATION(S)] (used to treat an overdose in an emergency) was administered and he/she was transferred to the emergency room (ER) for evaluation. […]

• Immediate jeopardy, isolatedF684Mar 13, 2026

  Based on interview and record review, the facility failed to respond to Resident #99's change in condition when the resident, who had a tracheostomy (surgical opening in the trachea to create an airway), experienced a change in breathing, becoming abnormally fast. Facility staff failed to complete a thorough, documented assessment and failed to contact the resident's physician in a timely manner. The resident expired at the facility. This deficient practice affected one out of three residents sampled. The census was 119.The Administrator was notified on [DATE] of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. […]

• Immediate jeopardy, isolatedF600Jun 20, 2025

  Based on interview and record review, the facility failed to ensure residents were free from neglect when staff failed to provide necessary services to avoid physical harm. On 5/26/25, Certified Nursing Assistant (CNA) D provided care to Resident #1, who had limited mobility after a stroke affecting his/her dominant side and an above the knee amputation. The resident had been assessed as needing total dependence on staff for personal hygiene and required substantial/maximal assistance to roll left to right. Resident #1 was left unattended in a raised bed when CNA D walked away to change his/her gloves. The resident fell out of the elevated bed onto the floor and was transported to the emergency room. […]

• Immediate jeopardy, isolatedF684Jun 20, 2025

  Based on interview and record review, the facility failed to follow their policy when a resident experienced a change in condition. Resident #1 fell out of an elevated bed onto the floor and was transported to the emergency room on 5/26/25. The resident sustained a fracture to his/her right femur (thighbone), and a contusion to his/her shoulder, The resident was readmitted to the facility on [DATE], with discharge instructions identifying symptoms to monitor for that may require the resident to return to the hospital. Facility staff documented a change in condition consistent with the hospital discharge instructions, including vomiting and lethargy, beginning on 5/29/25. […]