ElderGrade

Inspection citations at Willow Creek Post Acute

17 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2024 3 0
2023 14 1
E October 9, 2024 Tag F0761 Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

F October 9, 2024 Tag F0812 Corrected Nov 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D July 11, 2024 Tag F0686 Complaint investigation Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0808 Corrected Aug 2023

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0803 Corrected Aug 2023

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0758 Corrected Aug 2023

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0756 Corrected Aug 2023

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0732 Corrected Aug 2023

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0695 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0691 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0684 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0677 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D June 30, 2023 Tag F0584 Corrected Aug 2023

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

E June 30, 2023 Tag F0924 Corrected Aug 2023

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

No actual harm, potential for more than minimal harm

E June 30, 2023 Tag F0919 Corrected Sep 2022

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

E June 30, 2023 Tag F0727 Corrected Aug 2023

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

No actual harm, potential for more than minimal harm

G June 30, 2023 Tag F0697 Corrected Jul 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Actual harm to a resident

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.