Willows Health Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 25, 2025

  Based on observation, interview and record review the facility failed to follow speech therapy recommendations for a resident (R46) at risk for aspiration. The facility also failed to ensure a resident (R1) at high risk for falls and exhibiting restless behaviors was supervised. This failure resulted in (R1) falling from her wheelchair and sustaining a right hip fracture. This applies to 2 of 16 residents (R1, R46) reviewed for safety and supervision in the sample of 16.The findings include:1.) R1's face sheet shows she has diagnoses including Alzheimer's Disease, dementia, anxiety disorder, weakness, and a fracture of the neck of the right femur. […]

• Actual harm, isolatedF686Jul 20, 2022

  Based on observation, interview, and record review the facility failed to assess and implement treatment orders for a resident with pressure injuries for one of one resident (R25) reviewed for pressure injuries in the sample of 13. These failures resulted in R25's pressure injuries worsening. The findings include: R25's Braden Scale for Predicting Pressure Sore Risk dated 6/23/2022 shows R25 is at risk for pressure injury development. R25's Care Plan started 11/30/21 shows, Impaired skin integrity related to pressure ulcer plantar aspect of left heel, unstageable. Wound care/dressing change as ordered. Monitor wound progress and document and measure weekly. Notify medical doctor if wound does not demonstrate signs of healing. […]

• No harm, potential for more than minimal, widespreadF839Jan 26, 2026

  Based on interview and record review the facility failed to ensure nursing staff were working with an active nursing license which applies to all 91 residents in the facility. The findings include:The Facility Data Sheet dated 1/26/26 showed the facility had a current census of 91 residents.The facility's undated copy of V3's (Licensed Practical Nurse/LPN) from the state licensing agency summary showed V3's license was suspended from 12/15/25 through 12/24/25.V3's Timesheet Summaries printed on 1/26/26 showed V3 worked on 12/16/25, 12/19/25, and 12/23/25 during their license suspension.The Facility's Daily Census Sheets printed on 1/26/26 showed the on 12/16/25 was 67, 0n 12/19/25 the census was 64, and on 12/23/25 the census was 66.On 1/26/26 at 10:20 AM, V2 (Human Resources) stated V3… […]

• No harm, potential for more than minimal, widespreadF812Nov 25, 2025

  Based on observation, interview and record review that facility failed to store food in a sanitary manner and failed to ensure the cooking areas were clean and sanitary. This applies to all 35 residents residing at the facility. The findings include:The CMS 671 Long-term Care Facility Application for Medicare and Medicaid Form dated 11/24/25 shows that there are 35 residents residing in the facility. On 11/23/25 at 9:56 AM, during tour of the kitchen, there was an opened box of French baguettes stored directly below the condenser/evaporator in the walk-in freezer. There was an unwrapped French baguette sticking out of the top of the box. The box had ice build-up on the outside of the box. […]

• No harm, potential for more than minimal, widespreadF880Aug 22, 2024

  Based on observation, interview, and record review the facility failed to ensure their infection control policies and procedures were reviewed annually and update the policies to include Enhanced Barrier Protection (EBP) and failed to have measures to prevent the growth of Legionella in the facility water systems for all 30 residents residing in the facility reviewed for infection control. The findings include: 1. The facility's CMS form 671, the Long-Term care facility application for Medicare and Medicaid documents 30 residents reside in the facility. On 8/21/24 at 1:50 PM, V3 (Infection Preventionist) said no residents were on EBP and does not know about the requirements for EBP. […]