Inspection Reports for Willow Creek West AFC

The inspection was conducted as a renewal licensing study to verify compliance with licensing statutes and administrative rules and to approve the renewal of the facility's license.

The facility was found to be in substantial compliance overall but had non-compliance issues related to incomplete monthly weight records for residents and failure to complete required fire drills from January through July 2024. An acceptable corrective action plan was submitted and approved.

The investigation was initiated due to a complaint alleging that staff were not providing Resident A with a specific bedroom per a physician’s order, Resident A's dinner was served late, Resident A went three weeks without a shower, the facility was infested with mice, and the facility was unclean.

The investigation found no violation regarding the physician's order for Resident A's bedroom location or late dinner service. However, violations were established for Resident A going three weeks without receiving a shower and the facility being unclean due to mouse feces found in resident bedrooms despite ongoing pest control services. The facility is actively treating for mice but cleaning is required.

The complaint alleged that Resident A was not provided a bedroom per a physician’s order, dinner was served late, Resident A went three weeks without a shower, the facility was infested with mice, and the facility was unclean. The violation was substantiated for the showering and cleanliness issues but not for the bedroom assignment, dinner timing, or mice infestation.

The investigation was initiated due to a complaint alleging that Resident A was found covered in diarrhea after a fall at the facility on October 29, 2024, and concerns about the adequacy of care provided.

The investigation concluded that the allegation of Resident A being found covered in diarrhea was not substantiated, as staff provided appropriate care during the incident. However, violations were established related to Resident A's assessment plan and resident care agreement not being completed at the time of admission.

Complaint received on 2024-12-02 from Adult Protective Services alleging Resident A was found covered in diarrhea after a fall on 2024-10-29. The complaint was investigated and the violation regarding care was not established, but additional violations related to documentation were found.

The investigation was initiated due to a complaint alleging that Resident A was not provided ice on 6/12/24 at 4:00 pm when requested and that Resident A was not receiving his 8:00 pm insulin as prescribed.

The investigation found no violation regarding the denial of ice or nighttime snack and no violation regarding the administration of insulin at 8:00 pm. However, a violation was established for Resident A not receiving his 5:00 pm medications on 6/7/24 due to being out of the facility without proper documentation.

The complaint alleged that Resident A was denied ice at 4:00 pm on 6/12/24 and was not receiving his 8:00 pm insulin as prescribed. Both allegations were not substantiated. An additional finding of missed medication on 6/7/24 was substantiated.

The investigation was initiated due to a complaint alleging that facility staff administered the wrong medication to Resident A on 05/21/2024.

The investigation found no violation regarding the administration of the wrong medication to Resident A; staff administered the correct medication and dosage. However, a violation was established because Resident A routinely administers his own prescription injections without written physician approval.

Complaint alleged that on 05/21/2024 facility staff gave Resident A more than double dose of long-acting insulin and then took blood sugar after. The allegation of wrong medication administration was not substantiated.

The investigation was initiated due to a complaint alleging that facility staff yelled at Resident A and failed to obtain needed medical care for Resident A.

The investigation found no violation regarding staff yelling at Resident A. However, violations were established for failure to obtain needed medical care immediately for Resident A's infected tooth, failure to administer medications as prescribed, and failure to contact appropriate health care professionals after medication errors and resident refusals.

Complaint alleged that facility staff yelled at Resident A and failed to obtain needed medical care for Resident A's tooth pain. The allegation of yelling was not substantiated. The failure to obtain medical care and medication administration violations were substantiated.

The inspection was conducted in response to a complaint that Resident A did not receive her Klonopin medication on 9/6/23.

The investigation confirmed that Resident A missed her Klonopin dose on 9/6/23 due to pharmacy refill delays, with multiple other missed medication passes documented dating back to June 2023. Additionally, staff failed to notify Resident A's primary care physician about these medication errors.

The complaint alleged that Resident A was not given her Klonopin on 9/6/23. The allegation was substantiated with additional findings of multiple missed medication passes and failure to notify the physician.

The investigation was initiated due to complaints alleging staff misconduct including smoking marijuana and sleeping on the job, bringing children to work, inappropriate relationships between staff and residents, serving expired food, and a suspicious resident death.

The investigation found violations for staff bringing children to work and a former staff member having an inappropriate relationship with a resident. No violations were found regarding staff smoking marijuana or sleeping on the job, serving expired food, or suspicious death of a resident.

The complaint investigation was initiated on 2023-06-13 based on allegations including staff smoking marijuana and sleeping on the job (not substantiated), staff bringing children to work (substantiated), a former staff member having an inappropriate relationship with a resident (substantiated), serving expired food (not substantiated), and a suspicious resident death (not substantiated).

The inspection was conducted as a renewal inspection to determine compliance with licensing statutes and rules for the facility's license renewal.

The facility was found to be in substantial compliance with applicable licensing statutes and rules. An exit conference was held with the licensee designee, and the recommendation was made to issue a regular license for the adult foster care large group home.

The investigation was initiated due to a complaint from Adult Protective Services alleging that staff did not administer Resident A's prescribed Norco medication for pain management.

The investigation found that staff failed to ensure Resident A's Norco prescription was filled and administered, resulting in Resident A not receiving the medication from 02/24/2023 through 02/27/2023. Resident A was administered other pain medications but not Norco, and subsequently passed away on 03/03/2023. A violation was established for failure to administer prescribed medication.

Complaint received from Adult Protective Services on 03/02/2023 alleging failure to administer prescribed Norco medication to Resident A. Violation was substantiated.

The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the adult foster care facility.

The facility was found to be in substantial compliance with licensing requirements, including physical accessibility, safety features, staffing patterns, and administrative rules. A temporary license with a maximum capacity of 20 residents was recommended and issued.