Inspection Reports for
Willowcreek Wellness &Amp; Rehabilitation

The investigation was complaint-related, focusing on diabetes care deficiencies. The report states the level of harm as minimal and residents affected as few.

The facility failed to clarify a physician order for Resident #2 who was not monitored throughout the day for diabetes and failed to complete a follow-up accucheck for Resident #5 who had elevated blood sugar. Documentation and administration of insulin aspart were incomplete, and staff did not consistently follow physician orders for blood sugar monitoring and insulin administration.

The complaint investigation focused on Resident #1 who suffered from chronic pain and experienced multiple incidents of not receiving timely pain medication, leading to severe pain episodes and hospital transports. Resident #1 called 911 multiple times due to pain medication unavailability. The investigation also included Resident #2 and others with histories of substance abuse who overdosed multiple times in the facility and community, were allowed to leave the facility unsupervised, and returned intoxicated. Behavior contracts and interventions were inadequately implemented.

The facility failed to ensure timely ordering and administration of pain medication for a resident, resulting in severe pain and multiple hospital transports. Additionally, the facility failed to provide adequate behavioral health care and management for residents with substance abuse histories, allowing residents to leave the facility unsupervised, overdose multiple times, and return intoxicated. Behavior contracts and care plans were insufficiently enforced or updated.

The investigation was complaint-driven based on allegations of neglect resulting in a resident fall with injury and inadequate follow-up care. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to ensure residents were free from neglect, resulting in a resident falling from an elevated bed causing a femur fracture and contusion. The facility also failed to follow physician orders and properly monitor a resident's change in condition, which contributed to the resident's decline and death. Additionally, infection control practices were inadequate during wound care for multiple residents.

The complaint involved Resident #1 alleging that CNA A slammed him/her into the restroom and used rough handling during transfers. The grievance was not properly investigated or resolved, and the resident was not informed of the findings or given an opportunity to express satisfaction with the outcome. The facility classified the incident as a customer service issue rather than abuse and failed to document or notify appropriate parties as required.

The facility failed to follow its grievance policy by not maintaining an effective grievance process, failing to promptly resolve the grievance, and not providing the resident with investigation findings or follow-up. The facility also failed to complete a thorough investigation of the alleged abuse, lacking documentation of investigation findings, resident statements, and notification to appropriate agencies. Training was provided but not documented for the involved CNA.

The complaint involved Resident Council concerns not being addressed and allegations of abuse by Resident #3 and a staff member threatening Resident #15. The allegation by Resident #15 was not promptly investigated or reported to the State Survey Agency as required.

The facility failed to ensure concerns voiced during Resident Council meetings were consistently addressed in writing. Resident #3 exhibited bullying, verbal abuse, and threatening behaviors towards residents and staff, which were not adequately managed. The facility also failed to promptly investigate an allegation of staff verbal threat towards Resident #15. The facility did not consistently notify physicians or psychiatric providers of Resident #3's behaviors and failed to provide ongoing behavioral health care and monitoring. The Quality Assessment & Assurance Committee did not adequately address ongoing behavioral issues.

The complaint investigation focused on failure to obtain weekly weights as ordered and failure to notify the Registered Dietitian and physicians about weight loss and medication holds. The investigation found substantiated deficiencies related to these issues.

The facility failed to monitor one resident's weight weekly as ordered by the Registered Dietitian and failed to notify the physician when blood pressure medication was held due to hypotension. Additionally, the facility failed to obtain weekly weights for three residents with weight loss and failed to communicate this to the Registered Dietitian.

The complaint investigation revealed failures in wound care management, including improper dressing changes, inadequate infection control, and failure to follow physician orders. Resident #86 was sent to the emergency room with cellulitis following these deficiencies. Additionally, Residents #99 and #67 did not receive prescribed therapeutic diets or correct portion sizes.

The facility failed to ensure proper infection control during dressing changes, did not follow wound care orders for Resident #86, and improperly used a pillowcase with a rubber band to secure a dressing. Resident #99 did not receive therapeutic diets as prescribed, and portion sizes served were inconsistent with orders.

The facility was found deficient in multiple areas including medication administration practices, resident personal funds management, environmental maintenance, resident care including activities of daily living, wound care, oxygen therapy, dialysis care, feeding tube management, dietary services, use of bed rails, and clinical documentation. Several residents lacked proper assessments, physician orders, or documentation for care and treatments. The facility also failed to provide snacks at night and appropriate assistive devices for residents during meals.

The facility failed to maintain a homelike environment with issues such as damaged walls, leaking toilets, unclean bathrooms, and food debris. Therapeutic diets were not consistently provided as prescribed, with incorrect portion sizes served. Medication administration and required clinical assessments were inadequately documented for multiple residents, partly due to a recent change in ownership and loss of electronic medical records.

The complaint involved a physical altercation between Resident #1 and Resident #2 during an activity. Staff present, including the Activity Director and Activity Aide A, did not separate the residents promptly. The investigation included interviews with residents and staff, review of policies, care plans, progress notes, and training records. The facility also failed to timely respond to a resident (#9) experiencing prolonged seizure activity, delaying hospital transfer despite multiple staff observations and notifications.

The facility failed to keep residents free from physical abuse when two residents engaged in a physical altercation during an activity and staff present did not separate them. Additionally, the facility failed to adequately assess and respond to a resident experiencing prolonged seizure activity lasting 45 minutes, delaying hospital transfer.

The facility failed to follow wound treatment plan orders for three sampled residents, potentially affecting all residents receiving wound care. The wound treatments were not consistently documented or ordered correctly, and treatment frequency changes were not properly recorded.

The facility was found to have multiple deficiencies including failure to follow medication administration policies, failure to ensure resident safety and rights, inadequate staffing including lack of RN coverage, failure to maintain a safe and sanitary environment, failure to provide appropriate nutritional and hydration services, failure to ensure proper infection control practices, and failure to maintain safe physical environment such as secure handrails. An Immediate Jeopardy was identified related to a choking incident caused by failure to follow diet orders.

The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, incomplete financial notifications, lack of resident computer access, environmental issues in the dining room, improper use of restraints, failure to follow physician orders for treatments and medications, inadequate personal care, insufficient activity programming, medication errors, unsafe transfers, smoking policy violations, improper catheter care, dialysis care deficiencies, infection control lapses, and incomplete staff training documentation.