Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Creek Health Care during CMS and state inspections, most recent first.
Food was served below required hot holding temperatures for 50 of 51 residents receiving meals from dietary. Observations found cheeseburgers, corndogs, soup, hamburgers, chicken tenders, and tilapia sitting out or on the steam table at temperatures well below the facility’s 135 F hot-holding standard, and one resident received a cheeseburger at 91 F while another received tilapia at 103 F. Staff stated the food was not reheated because residents do not like it steaming hot, while the CDM, Administrator, QA Corporate Nurse, and DON stated meals were expected to be held above 135 F and reheated or remade if not at the proper temperature.
The facility failed to maintain an infection prevention and control program for monitoring its water system for potential waterborne pathogens and failed to ensure proper hand hygiene during meal service. The Maintenance Director stated the facility had no water system flow diagram, had not assessed areas where water could accumulate, and had not implemented control measures, while the IP was unaware of any such measures. During lunch service, two students touched a resident and their own clothing and hair before assisting with a beverage, and a dietary aide and other dietary staff repeatedly handled plates, a mask, papers, and other surfaces without repeating hand hygiene between residents or after contamination.
A CNA failed to treat two residents with dignity and respect. One resident with intact cognition and anxiety/depression was asked if they were a gang banger, and when the resident tried to explain their tattoos, the CNA became frustrated and disengaged. Another resident with dementia and dependence for eating did not receive attentive mealtime assistance: the CNA stopped assisting to talk with others, ate her own meal, placed food and drinks into the resident’s mouth without warning, and seasoned the resident’s food without asking.
A resident with cerebral infarction, dementia, and gastrostomy status had a pressure pad call light repeatedly observed out of reach in bed, including clipped to the bed, attached to the privacy curtain, and placed beside the resident’s head. An LPN, CNA, DON, and the Administrator all stated the call light should have been within the resident’s reach and that the observed placements were not appropriate.
Failure to complete PASARRs for residents with newly identified mental health diagnoses. Three residents had mental health diagnoses documented on their records and MDSs, including anxiety, depression, dysthymic disorder, and major depressive disorder, but no new PASARR was completed for the added diagnoses. The DON stated she should have completed the PASSARs, and the Administrator stated staff were expected to complete them for new mental health diagnoses.
Inaccurate PASARR screenings were identified for two residents with anxiety and depression diagnoses. One resident had intact cognition and received antianxiety and antidepressant medications, while the other had severe cognitive impairment and also received antianxiety and antidepressant medications. In both cases, the Level I PASARR screens were marked No for serious mental illness and related history, and the DON stated the mental health diagnoses should have been reflected on the PASARRs.
Incomplete Daily Nurse Staffing Postings: The facility failed to post complete daily nurse staffing information for every shift over a 30-day review period. The postings did not include the facility census, the total number of licensed and unlicensed staff, or the actual hours worked by staff directly responsible for resident care. During interview, the ADON stated she prepared the staffing information and was responsible for the posting.
A facility failed to follow infection control protocols during an insulin injection for a resident. An LPN administered insulin without wearing gloves or cleaning the injection site with alcohol, contrary to the facility's policy. The LPN acknowledged the mistake, and an RN confirmed the correct procedure. This incident involved one of the eight residents receiving insulin in the facility.
Food Served Below Required Hot Holding Temperatures
Penalty
Summary
The facility failed to ensure food was served at safe temperatures for 50 of 51 residents who received meals from the dietary department. A facility policy titled, Food Holding and Service, required all hot foods to be served at 135 F or greater and all cold foods at 41 F or less, with temperatures adjusted for the time food would be held prior to service. During a kitchen observation, two plates of cheeseburgers and a plate of corndogs were found sitting out next to the steam table, and temperatures taken with a facility-issued digital thermometer showed the cheeseburger at 120 F and the corndogs at 121 F. A bowl of chicken noodle soup was poured from a can and microwaved to 129 F. Later, Resident #49 received a cheeseburger at 91 F. During another meal observation, a hamburger plate and a plate of chicken tenders were observed sitting out next to the steam table, with temperatures of 104.5 F and 126.3 F, respectively. An employee stated the food was not reheated because residents do not like their food steaming hot. In the upstairs dining area, tilapia was observed on the steam table at 109.7 F, and Resident #18 was served the tilapia at 103 F. The CDM stated food was expected to be taken at the end of cooking, held above 135 F, and reheated to 165 F if it was not at the proper hot holding temperature. The Administrator, QA Corporate Nurse, and DON each stated staff were expected to hold meals above 135 F and reheat or remake food that was not at the proper temperature.
Infection Prevention and Hand Hygiene Failures During Water System Monitoring and Meal Service
Penalty
Summary
The facility failed to develop, implement, and maintain a process for monitoring its water system for potential waterborne pathogens. The facility’s Infection Prevention and Control Program and Legionella Surveillance and Detection policies stated that control measures and testing protocols were in place to address hazards associated with the water system and that the facility was committed to the prevention, detection, and control of water-borne contaminants. However, the Maintenance Director stated the facility had last tested water for Legionella on 11/05/2025, did not have a flow diagram of the water system, had not assessed locations in the two-story building where water may be held or accumulated, and had not implemented control measures to mitigate potential waterborne pathogens. The QACN, who was the IP, stated she was unaware of any control measures as part of the Infection Control and Prevention Program, and the Administrator confirmed the facility did not have a flow diagram or control measures in place. The facility also failed to ensure hand hygiene was performed during meal service by nursing assistant students and dietary staff. During lunch service, two students sitting with a resident touched the resident’s bib cover, clothing, their own scrub clothing, their laps, and their hair before assisting the resident with a beverage; the Student Preceptor then intervened and provided ABHS before they continued assisting the resident. The Student Preceptor stated it was the students’ first day in the facility and confirmed they had potentially contaminated their hands by touching the resident, their clothing, and their hair prior to assisting with the beverage. During the same meal service, a dietary aide served plates of food without repeating hand hygiene between residents, touched the edges of plates including the food area with an ungloved hand, touched her mask, entered the kitchenette office area and touched the doorknob and items inside, and then returned to serving residents without repeating hand hygiene. In a separate observation, a dietary staff member repeatedly touched diet roster papers, adjusted their mask, and touched the face of residents’ plates while preparing lunch plates, without observed hand hygiene between those actions. The Certified Dietary Manager, DON, IP, and Administrator all stated staff were expected to use proper hand hygiene when touching different surfaces and while serving residents’ meals, and the dietary staff acknowledged not repeating hand hygiene after touching the mask, plates, and other surfaces.
Failure to Treat Residents with Dignity During Conversation and Mealtime Assistance
Penalty
Summary
The facility failed to treat residents with dignity and respect for two residents reviewed for dignity. One resident had diagnoses of generalized anxiety disorder and recurrent depressive disorder, had a BIMS score of 15 indicating intact cognition, and had care plan interventions directing staff to face the resident when speaking and provide a calm environment. During an observation in the dining room, a CNA asked this resident if they were a gang banger. The resident attempted to explain the history of their tattoos, but the CNA crossed her arms, appeared frustrated, stated she needed a break from the resident, and later left the table. The resident stated the comment was not nice and that the CNA would not answer them back while they were trying to explain. A second resident had dementia, severe impairment in cognitive skills for daily decision-making, short- and long-term memory problems, and was dependent on staff for eating. The resident’s care plan directed staff to provide setup assistance for eating and encourage the resident during meals as needed. During dining observations, the CNA sat beside the resident but stopped assisting when speaking with a visitor, while the resident began feeling for the plate and using fingers to eat. The CNA did not interact with the resident or ask if assistance was needed, and at one point placed a spoon to the resident’s mouth without speaking, startling the resident. Additional observations showed the CNA continued to eat her own meal while the resident was still eating and needed assistance. On another occasion, the CNA again sat beside the resident, talked with other staff, and repeatedly attempted to place food into the resident’s mouth while the resident was still chewing. The CNA also poured sweet and sour sauce on the resident’s rice without asking and put a cup to the resident’s mouth without notifying the resident, causing the resident to startle when the cup touched their lips. Staff interviews stated residents should be interacted with during meals, allowed to chew and swallow before more food or drinks were offered, and asked before seasoning food. The DON and Administrator stated they expected staff to interact appropriately, ask before seasoning food, and wait until residents had swallowed before offering more food.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure the call light was maintained within reach for a resident who was readmitted with diagnoses including cerebral infarction, unspecified dementia, gastro-esophageal laceration-hemorrhage syndrome, and gastrostomy status. The resident’s quarterly MDS indicated severe impairment in cognitive skills for daily decision making, short- and long-term memory problems, and dependence on staff for all ADLs. The care plan identified the resident as being at risk for serious injury related to falls and directed staff to keep the call light, personal items, and frequently used items within easy reach. Multiple observations showed the resident’s pressure pad call light placed out of reach in different locations, including clipped to the top left side of the bed, attached to the privacy curtain about three feet from the bed, attached to the right top corner of the sheet hanging over the bed, and sitting beside the resident’s head on the bed. During concurrent and subsequent interviews, an LPN, another LPN, a CNA, the DON, and the Administrator all stated that call lights should be within the resident’s reach and that the placements observed were not appropriate because the resident could not reach them.
Failure to Complete PASARRs for Newly Identified Mental Health Diagnoses
Penalty
Summary
The facility failed to complete PASARRs for residents with newly identified mental health diagnoses for 3 of 3 sampled residents reviewed for PASARR. Facility policy titled, Resident Assessment - Coordination with PASARR Program, dated 10/2025, stated that any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition would be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Resident #7 was admitted with diagnoses that included delusional disorders, anxiety disorders due to known physiological condition, and depression, and later had diagnosis list entries for anxiety disorders and depression without a new PASARR being completed. Resident #42 was admitted with dysthymic disorder and later had dysthymic disorder added to the diagnosis list without a new PASARR being completed. Resident #48 was admitted with major depressive disorder and had that diagnosis added to the diagnosis list without a new PASARR being completed. The DON stated she should have completed new PASSARs for these residents when the new mental health diagnoses were identified, and the Administrator stated she expected staff to complete the PASSARs for a new mental health diagnosis.
Inaccurate PASARR screenings for residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure PASARR screenings were accurate for 2 residents reviewed for PASARR. A facility policy stated the facility coordinates assessments with the PASARR program to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs. For Resident #42, the resident was admitted with diagnoses of anxiety disorder and depression, had a BIMS score of 15 indicating intact cognition, and received antianxiety and antidepressant medications during the MDS look-back period. However, the Nursing Facility Level of Care Assessment marked No for evidence of serious mental illness, a diagnosis of serious mental illness, and a recent history of mental illness. The DON stated the admitting diagnoses of anxiety and depression should have been on the resident's PASARR. For Resident #48, the resident was admitted with diagnoses of anxiety disorder and depression disorder, had severe impairment in cognitive skills for daily decision-making with short-term and long-term memory problems, and received antianxiety and antidepressant medications during the MDS look-back period. The Nursing Facility Level of Care Assessment again marked No for evidence of serious mental illness, a diagnosis of serious mental illness, and a recent history of mental illness. The DON stated Resident #48's PASARR should have reflected the resident's mental health diagnoses, and the Administrator stated she expected staff to make sure the PASARRs on admission were correct.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to complete daily nurse staffing data for each shift for 30 of 30 days reviewed, from 06/14/2026 through 07/13/2026. The posted staffing information did not include the facility census, the total number of licensed and unlicensed staff, or the actual hours worked by licensed and unlicensed staff who were directly responsible for residents' care. During an interview on 07/13/2026 at 10:15 AM, the ADON stated that she had prepared the nurse staffing information and was responsible for the posting.
Failure to Follow Infection Control Protocols During Insulin Injection
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during an insulin injection for a resident. Specifically, a Licensed Practical Nurse (LPN) was observed administering insulin to a resident without wearing gloves and without cleaning the injection site with alcohol, as required by the facility's Subcutaneous Injections policy dated March 2011. The LPN acknowledged the oversight immediately after the injection. Additionally, a Registered Nurse (RN) confirmed that the staff should have worn gloves and used alcohol on the site prior to the injection. This incident involved one resident out of the eight who received insulin in the facility, which housed a total of 51 residents at the time of the observation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Guthrie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Age Nursing Home Of Guthrie, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Bradford Village Healthcare Center | 12.7 mi | ★★★★★ | 0 | 0 |
| The Timbers Skilled Nursing And Therapy | 17.3 mi | ★★★★★ | 6 | 2 |
| Edmond Health Care Center | 17.8 mi | ★★★★★ | 10 | 0 |
| Ignite Medical Resort Edmond, Llc | 18.8 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Willow Creek Health Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.