Willows Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 21, 2021

  Based on observation, interview and record review the facility failed to ensure an environment free from abuse and neglect when: 1. A wandering resident (Resident 6) did not have care plan interventions in place to address his dementia (a group of symptoms that affects memory, thinking and interfers with daily life) and behavioral needs to prevent resident to resident altercations. 2. The facility did not provide sufficient staffing to ensure the protection and safety for all 58 residents including not providing staff for 24 hour, 7 day a week 1:1 care for Resident 6. The failure to protect and ensure the safety of all 58 residents resulted in two resident to resident altercations with injuries and resident fear and anxiety. […]

• Actual harm, isolatedF689Oct 11, 2022

  Based on observation, interview, and record review, the facility failed to ensure that residents were safe from accidents when: 1) The facility did not have policies regarding resident care in hot weather, or resident patio use, and 2) One of six sampled residents (Resident 2) was allowed outside during peak temperatures, left unattended on an outdoor patio for an unknown length of time in hot weather and was found unresponsive on the patio. The patient expired. These failures had the potential to contribute to the death of Resident 2 and endanger all residents by providing patio access during high temperatures with no care plan in place to ensure safe use. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2024

  Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in accordance with professional standards for food service safety when: 1. A slimy, brown-pink substance was found inside the holding tray of the facility's icemaker. 2. Dirty dishwasher water from the dishwasher's air gap (directs dirty dishwater from a pipe in the dishwasher to a drain in the floor to prevent it from backing up onto clean dishes) was splashing onto floor tiles next to the drain. 3. A kick plate at the bottom of an oven/stove unit was missing, exposing wires and other internal parts. These failures created safety issues for staff and had the potential to cause avoidable food- or waterborne illness for all 68 facility residents. Findings: 1. […]

• No harm, potential for more than minimal, patternF550Aug 14, 2025

  Based on observation, interview and record review, the facility failed to provide services that promoted respect and dignity for four of four sampled residents (Resident 1, 2, 3, and 4) when direct care staff did not respond and help residents dependent on staff with their requests for assistance. These failures resulted in residents feeling afraid to ask for assistance, uncomfortable, and unwanted. Findings: 1. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/25 and medical record, indicated Resident 1 was cognitively intact with no memory issues. The MDS indicated Resident 1 required assistance with most activities of daily living (ADLs). […]

• No harm, potential for more than minimal, patternF584Apr 4, 2024

  Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable, and homelike environment when: 1. Varnish was worn off the wooden handrails in Unit 1 (hallway between Rooms 27-34 and hallway between Station 1 nurses' desk and patio). 2. Wall paint was scratched or in disrepair in Rooms 6, 10, 30, and 37, and curtains were missing in room [ROOM NUMBER]. These failures violated all (68) facility residents' rights to a clean, comfortable, homelike environment; diminished their quality of life; and increased the potential risk for infection from exposure to germs on uncleanable surfaces. FINDINGS: 1. […]