Willowcrest

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 5, 2026

  Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Observations conducted on December 29, 2025, at 9:56 a.m. with the Food Service Director (FSD), Employee E4, and Chef, Employee E5, in the main kitchen revealed food items were improperly labeled, undated, uncovered, or stored in a manner that could lead to contamination. Observations in the main refrigerator revealed blue cheese (2lbs- pounds) that was undated and additional 3 lbs. without a use-by-date; 3lbs of Monterey [NAME] cheese with no date; 5 lbs. […]

• No harm, potential for more than minimal, isolatedF628Jan 5, 2026

  Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understood for one of three closed records reviewed (Resident R50).Findings include: Review of Resident R50's medical records revealed that on December 11, 2025, the resident was admitted to the hospital for shortness of breath. Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator, Employee E1 on January 5, 2026, at 1:00 p.m. […]

• No harm, potential for more than minimal, isolatedF657Jan 5, 2026

  Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to review and revise a resident care plan with new interventions status prior and post a fall incident for one of 12 residents reviewed (Resident R24).Findings include:Review of facility policy titled Resident Assessment and Plan of Care revised July 2018 states the process of systematically reviewing a resident's physical functional mental and psychological status to identify strengths and weaknesses for which the interdisciplinary team can develop a plan of care for each resident. […]

• No harm, potential for more than minimal, isolatedF677Jan 5, 2026

  Based on review of resident clinical records, facility documentation and interview with staff, it was determined that the facility failed to ensure an incontinent resident who was unable to carry out activities of daily living received the appropriate services with toileting for one of 12 resident records reviewed (Resident R24).Findings include: Review of Resident R24's occupational therapy (OT) assessment notes dated November 20, 2025, revealed the resident was admitted to the facility on [DATE], with a history of traumatic intracranial hemorrhage (bleeding in the brain), right Middle Cerebral Artery (aka MCA stroke) in October 2025 which left the resident with left residual weakness and left sided body pain. […]

• No harm, potential for more than minimal, isolatedF684Jan 5, 2026

  Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure care and treatment were provided in accordance with physician orders for one of 12 residents reviewed. (Resident R3)Findings Include: Review of resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including fractures, foot drop (inability lifting the front part of the foot). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of nine, indicating moderate cognitive impairment. […]