Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowcreek Rehab And Nursing during CMS and state inspections, most recent first.
A CNA was observed standing over residents while assisting them with meals and staff referred to residents needing feeding help as "feeders." Three residents with severe cognitive impairment and significant care needs were involved, including one who required maximal assistance with eating and another who had to be redirected constantly during lunch. The DON and an LVN stated staff should sit at eye level and address residents by their preferred names, and the report identified the issue as a dignity concern.
Failure to Deliver Resident Mail on Saturdays: The facility failed to ensure residents received mail on Saturdays, and 5 of 5 residents interviewed said they only got mail Monday through Friday because office staff did not work weekends. The AD said she handled mail during the week and there was no weekend assignment, while the DON and ADMN stated residents should have received mail on Saturdays and noted mailbox key access issues and weekend staffing gaps.
Inadequate Hot Water in Resident Room Sinks: The facility failed to ensure hot water was available in multiple resident room sinks and an East side conference room toilet room sink. Staff observed the water felt cold and measured temperatures ranged from 66.3 to 87.0 degrees F after running for 1 minute. An LVN reported notifying the maintenance director that the water was not coming up to temperature, while the MA and admin stated hot water was expected to be available in the bathrooms.
Medication administration errors resulted in an 11.5% error rate, exceeding the allowed threshold. A resident with dysphagia received acetaminophen in an incorrect form/dose, a resident with DM received an excessive total dose of insulin aspart after a high BG reading, and a resident with CHF was given metoprolol succinate ER instead of the ordered metoprolol tartrate. Staff and leadership stated meds were expected to be given per the physician order and EMAR.
Soiled Secure Unit Refrigerator Without Temperature Logs: The secure unit refrigerator used for patient snack storage was observed dirty, with dried food, spilled punch, dust, dirt, and ice buildup in the freezer portion. No temperature logs were attached, and the monthly log at the nurse's station was blank. The DON said night nurses were responsible for cleaning the refrigerator and taking temperatures, but she did not know why the log had not been completed.
Failure to follow EBP during wound care for a resident with a wound and pressure ulcer. An RN entered the room with an EBP sign posted and PPE available, but provided wound care without donning a gown. The RN said she forgot to put on a gown because the resident was on EBP, and the DON stated staff were expected to gown and glove for residents on EBP. The facility policy required gowns and gloves before high-contact care activities such as wound care.
Surveyors found that dietary staff failed to follow food safety protocols, including improper use of hair restraints and inadequate hand hygiene during meal preparation. Staff were observed with exposed hair while wearing hair nets and handled food and kitchen equipment without washing hands or wearing gloves, despite facility policies requiring these practices. Staff and management acknowledged these lapses and the potential for contamination.
Nursing staff failed to document wound care and catheter-related interventions for two residents with complex medical needs, resulting in incomplete medical records. Despite care plans and physician orders requiring daily wound and catheter care, treatment administration records lacked documentation for these interventions on multiple occasions. Staff interviews confirmed that care was performed but not recorded due to distractions and workload, contrary to facility policy requiring immediate and accurate documentation.
A wound care nurse/acting DON did not perform hand hygiene between glove changes while providing incontinent and wound care to a resident with chronic wounds and incontinence, despite the resident being on enhanced barrier precautions. The nurse changed gloves multiple times without washing or sanitizing hands, contrary to facility policy and expectations.
The facility failed to maintain hot water temperatures below 110°F, leading to an Immediate Jeopardy situation. Observations revealed excessively hot water in resident areas, posing a risk of severe burns. Inadequate monitoring and maintenance of the water system, along with insufficient staff awareness, contributed to the deficiency. Residents with cognitive and physical impairments reported experiencing dangerously hot water, necessitating manual adjustments or assistance.
The facility failed to ensure the activities program was directed by a qualified professional, as the current Activity Director (AD) lacked the necessary certification or training. The AD, who started in the position recently, was working towards certification but had not yet obtained it. The Administrator acknowledged the requirement for a licensed AD and took responsibility for the oversight, citing the AD's previous experience and rapport with residents as mitigating factors.
The facility failed to ensure timely physician visits for three residents within the required timeframes after readmission, as documented in their progress notes. This deficiency was due to staffing changes and inadequate monitoring by the Medical Records staff and DON, potentially impacting the residents' health care.
The facility failed to follow food safety and hygiene standards, as the Dietary Aide did not wear a beard cover in the kitchen, and both the CNA and Activities Director neglected hand hygiene while serving food. These actions were contrary to the facility's policy and FDA guidelines, potentially risking cross-contamination and health issues for residents.
The facility failed to maintain a sufficient surety bond to cover the total residents' trust fund balance, with a bond amount of $30,000 falling short of the $32,266.35 average balance. The Administrator was unable to explain the discrepancy, attributing it to possible changes in census or consulting transitions, but believed it did not affect residents.
A resident was admitted to the Memory Care Unit without a signed consent, violating facility protocol. The resident, with dementia and cognitive deficits, was placed in the secured unit without documented consent from her or her representative. Staff interviews revealed that the failure was due to personnel changes and inconsistencies in the admission process, with the responsibility for obtaining consents not clearly managed.
A facility failed to complete a baseline care plan within 48 hours for a newly admitted resident with multiple medical conditions, including COPD and chronic pain. The resident was cognitively intact, but the care plan was delayed due to the admission occurring on a Friday evening. The DON acknowledged the oversight, which could have impacted the resident's care needs.
A medication cart was found unlocked and unattended in a facility, with RN B responsible for the oversight. The cart contained various medications, including cardiac and blood pressure medications. RN B admitted to being distracted and forgetting to lock the cart, despite being trained to do so. The facility's policy requires all drugs to be stored in locked compartments to ensure security.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal assistance for 3 of 12 residents reviewed for dignity. Surveyors observed CNA E standing over Resident #62, Resident #45, and Resident #22 while assisting them with eating in the dining area, and the CNA was also observed moving from one resident to another while providing meal assistance. The report states that staff referred to residents who needed help with eating as "feeders," and the DON and LVN both stated that staff should not stand over residents and should instead sit at eye level and address residents by their preferred names. Resident #62 was an [AGE]-year-old female with dementia, muscle wasting and weakness, and anxiety disorder. Her quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and she required substantial to maximal assistance with eating. Her care plan noted that she was on a regular diet with thin liquids and was at nutritional and hydration risk related to dementia. During observation, CNA C was seen standing over Resident #62 and placing food in her mouth with a utensil while the resident had to be redirected constantly to remain seated at the bedside table in the secure unit dining room. Resident #45 was an [AGE]-year-old female with adjustment disorder with depressed mood, protein calorie malnutrition, dementia, and anxiety disorder. Her MDS reflected severe cognitive impairment, inability to complete the BIMS, and need for setup and cleanup assistance with eating. Resident #22 was an [AGE]-year-old female with obesity, chronic oral aphthae, decreased mobility, and major depressive disorder with psychosis; her MDS showed severe cognitive impairment, inattention, disorganized thinking, maximal assistance with eating, and significant weight loss. Her care plan noted that she would grab food off other residents' trays, the food cart, and the trash can. The DON stated the behavior was a dignity issue and that staff should not use labels such as "feeders" or stand over residents during meal assistance.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents had the right to send and receive mail and to receive letters, packages, and other materials delivered to the facility through a means other than postal service, including privacy of those communications, for 5 of 5 confidential residents reviewed for resident rights. During a confidential group interview, all 5 residents stated they did not receive mail on Saturdays because office staff did not work on Saturdays, and that mail was delivered only Monday through Friday. During interviews, the AD stated she was responsible for getting resident mail during the week, Monday through Friday, and that before the day of the interview there was no staff member assigned to get mail on weekends. The DON stated she expected residents to get mail on Saturdays and that the facility was planning for a Saturday nurse and weekend supervisor to ensure mail was passed out, noting there was only one key to the mailbox at the time. The ADMN stated mail should have been delivered on Saturdays, that there was only one key and the AD had it, and that he was not aware the mail was not being delivered. Record review of the facility policy titled, Resident Right to Privacy in Communication, stated the facility would honor the resident's right to privacy in written communications and that the social service designee or another designated staff member would ensure each resident receives mail addressed to that resident promptly.
Inadequate Hot Water in Resident Room Sinks
Penalty
Summary
The facility failed to provide maintenance services necessary to maintain a sanitary and comfortable environment by not ensuring hot water was available in resident room sinks and the East side conference room toilet room sink. During observations, the water in the sinks shared by rooms 101/103, 102/104, and other East side rooms felt cold, and measured temperatures included 79.7 degrees F, 78.4 degrees F, 86.3 degrees F, 86.2 degrees F, 87.0 degrees F, 66.3 degrees F, and 77.3 degrees F after the water had run for 1 minute. The East side conference room toilet room sink also had water that was not hot, with a measured temperature of 87.0 degrees F after running for 1 minute. During interview, an LVN stated she had verbally notified the maintenance director that morning that the water was not coming up to temperature, and she would want hot water in the sink if she lived at the facility. An MA stated she expected hot water to be available in the bathroom and observed that running cold water did not improve the temperature. The maintenance director stated she had been taking weekly water temperatures and had not been told the water was not hot in rooms 101-103 or 102-104; she also stated the facility had previously had issues with hot water being too hot and had installed an aquastat to regulate temperature. The administrator stated residents should have access to hot water in their room bathrooms. Weekly water temperature logs for April 2026 showed temperatures of 100 to 103 degrees in rooms 101/103 and 102/104, with no temperatures below 100 recorded.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, with a reported error rate of 11.5% for 3 of 5 residents reviewed for medication administration. During observation and record review, Resident #10, who had dysphagia following a cerebral infarct and an order for acetaminophen 500 mg, 2 tablets via PEG tube every morning and at bedtime, was given Tylenol 160 mg/5 ml, 30 ml instead of the ordered tablet dose via PEG tube. Resident #20, who had diabetes mellitus and an order for insulin aspart 12 units before meals for hyperglycemia plus sliding-scale dosing, had a blood glucose of 317 and was given 12 units of insulin aspart SQ plus an additional 12 units, for a total of 24 units. Resident #25, who had unspecified diastolic congestive heart failure, had an order for metoprolol tartrate 25 mg, 1/2 tablet (12.5 mg) twice daily by mouth, but during observation was given metoprolol succinate extended release 1/2 tablet by mouth instead. The report also states that the Regional Nurse and DON identified that medications were expected to be administered according to the physician orders and package label, and that giving the wrong dose or form could lead to adverse effects or an unintended therapeutic response. Facility policy required medications to be administered according to manufacturer guidelines and physician orders, with verification against the EMAR before administration.
Soiled Secure Unit Refrigerator Without Temperature Logs
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 refrigerator in the secure unit. During observation in the secure unit lobby, the small refrigerator used for patient snack storage was found soiled with dried food, spilled punch in the bottom, dust and dirt, and ice buildup in the top freezer portion that needed to be defrosted. The outside of the refrigerator was also covered in dust on the top, and there were no temperature logs attached or evidence that daily temperatures were being taken. In an interview and observation with the DON, she stated the night nurses were responsible for cleaning the refrigerator and taking temperatures. The temperature log for May 2026 was observed at the nurse's station and was blank, and the DON did not know why it had not been filled out. The facility policy required refrigerator and freezer temperatures to be checked and logged a minimum of twice daily, and the FDA Food Code cited that nonfood-contact surfaces of equipment shall be kept free of dust, dirt, food residue, and other debris.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections for one resident reviewed for infection control. Resident #70 was a cognitively intact female with diagnoses including embolism and thrombosis of the arteries of the lower extremities and cerebral infarction, and her record also showed a stage 2 pressure ulcer. Her physician orders required Enhanced Barrier Precautions for a wound to the right ankle, with gown and gloves required for high-contact resident care activities, including wound care, bathing, personal hygiene, device care, toileting, incontinence care, and transferring. During observation, RN C entered the resident’s room to perform wound care while an Enhanced Barrier Precautions sign was posted on the door and PPE was available inside the room. The wound care was provided without the RN donning a gown, and at the end of the procedure the RN stated she forgot to put on a gown because the resident was on Enhanced Barrier Precautions. The DON stated it was her expectation that staff gown and glove when providing care to residents on Enhanced Barrier Precautions, and the facility policy stated that gowns and gloves were required before high-contact care activities such as wound care.
Failure to Maintain Food Safety Standards in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food safety and sanitation practices. Dietary staff were seen wearing hair nets that did not adequately cover their hair, with several inches of hair exposed at the forehead, neck, and around the head. Staff acknowledged difficulties with the provided hair nets, stating they often slipped and failed to contain all hair, which could result in hair falling into food and causing contamination. During meal preparation, staff were observed handling food and food containers without wearing gloves and without practicing appropriate hand hygiene. One staff member touched the inside of dessert bowls and a container of liquid with bare hands, then continued to prepare and serve food without washing hands. The same staff member also scratched her forehead and handled kitchen equipment and food items without washing hands between tasks. These actions were observed both after entering the kitchen and after handling potentially contaminated items, in direct violation of the facility's hand hygiene policy. Interviews with dietary staff, the Dietary Manager, and the DON confirmed awareness of the facility's policies requiring thorough hand washing at the start of shifts, after leaving and re-entering the kitchen, and after touching hair or face. Staff admitted to not following these protocols during the observed periods, and acknowledged the potential for contamination when proper hygiene is not maintained. The facility's policy on food safety and sanitation specifically outlines the need for personal hygiene practices, including hand washing and effective hair restraint, which were not adhered to during the survey.
Failure to Document Wound and Catheter Care in Accordance with Professional Standards
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. Specifically, nursing staff did not document wound care and catheter-related interventions for residents with significant medical needs. On two separate dates, there was no documentation of wound care for open areas on the right and left buttocks for both residents, nor was there documentation of catheter care, including the use of a privacy bag, catheter securement device, and the presence of a 16 French catheter to bedside drainage. Resident 2, a male with hemiplegia and prostate cancer, had care plans and physician orders requiring daily wound care for moisture-associated skin damage and regular catheter care. Resident 4, a female with right-side hemiplegia and aphasia, also had orders for wound care to multiple areas on her buttocks. Despite these orders, the treatment administration records for both residents showed missing documentation for the required care on the specified dates and shifts. Interviews with the involved RNs and LVNs revealed that while they stated the care was provided, they admitted to forgetting to document the interventions due to being called away or becoming busy. The Acting DON confirmed that documentation was expected to be completed accurately and acknowledged that the errors were due to staff not paying attention and failing to document their work. Facility policy required immediate documentation of treatments and review of records before the end of each shift, which was not followed in these instances.
Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound and incontinent care for a resident. Specifically, the wound care nurse/acting DON did not perform hand hygiene between glove changes while providing care to a female resident with right side hemiplegia, aphasia, chronic wounds, and a history of incontinence. The resident was on enhanced barrier precautions due to wounds, and signage and PPE were in place as per care plan requirements. During the observed care, the nurse donned gloves and a gown but did not wash or sanitize her hands between glove changes after performing incontinent care and before wound care. She also failed to perform hand hygiene after removing soiled dressings and before applying clean gloves and dressings. Both the nurse and the RNC acknowledged that hand hygiene should have been performed between glove changes, as outlined in the facility's hand hygiene policy, which requires hand hygiene before donning and after removing gloves.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures below 110°F in several resident areas, leading to an Immediate Jeopardy situation. Observations revealed that water temperatures in multiple locations, including resident sinks and shower rooms, were significantly above the safe limit, with some reaching as high as 150°F. This posed a risk of severe burns to residents, as confirmed by interviews with residents and staff who reported fluctuating and excessively hot water temperatures. The deficiency was further compounded by inadequate monitoring and maintenance of the water temperature system. The maintenance manager admitted to issues with the temperature gauge on the boiler mixer, which had been problematic since a new pump was installed. Despite regular checks, the maintenance logs lacked comprehensive documentation, with some rooms not being checked and others showing temperatures above the safe limit. Interviews with staff indicated a lack of awareness and reporting of the hot water issue, contributing to the ongoing risk. Residents affected by the deficiency included individuals with varying degrees of cognitive and physical impairments, such as severe impairment and chronic conditions. These residents reported experiencing excessively hot water, which they had to manually adjust or seek assistance for. The facility's failure to address the longstanding issues with the water system and ensure consistent monitoring and reporting of water temperatures led to the identification of Immediate Jeopardy, highlighting the potential for serious harm to residents.
Removal Plan
- The maintenance director turned off all hot water in all resident rooms.
- All shower rooms were secured by the Maintenance Director with key codes/or pad locks and do not enter signs were placed on the door taking them out of service until further notice.
- All staff were in-serviced that hot water was turned off in resident rooms, and all shower rooms were secured and out of service.
- The hot water issues were fixed by the Plumbing company by adding 2 new recirculating pumps, re-routing the plumbing to the mixing valve, and adding 2 new thermostats.
- The Maintenance Director completed testing all hot water in all resident rooms and shower rooms with no hot water temperatures found to be above 110 degrees.
- The DON/Designee completed head-to-toe skin assessment for residents 60, 168, 167, and residents #14 and no skin issues identified.
- While testing hot water Temps. It was noted that the facility had hot water temps. Above 110 degrees, so all hot water was again immediately turned off. The Plumbing Company was immediately notified.
- All staff were alerted that hot water would again be shut off to the facility.
- The DON/Designee completed head-to-toe skin assessment for all other residents throughout the facility, and no issues identified.
- The DON/Designee began in-service education with all staff on hot water being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms.
- Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended.
- This education will be provided for all new hires and any agency staff going forward as part of new hire orientation.
- The Regional Nurse consultant provided 1:1 in-service with the Maintenance Director regarding the hot water system and taking and recording hot water temperatures.
- Every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water temp. testing.
- If at any time the hot water temp. exceeds 110 degrees, the hot water will be turned off, The Plumber will be notified for repairs/services, and the monitoring process above will continue until the hot water temperatures remain between 100 and 110 degrees.
- On Schedule of checking hot water temps. Weekly, rotating rooms, bathrooms etc., ensuring that all rooms and shower room hot water temps are taken and recorded during the month and hot water temperatures remain between 100 and 110 degrees.
- DON/Designee start in-service training with all staff related to hot water being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms.
- Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended.
- To turn hot water off immediately and notify charge nurse if at any time water temps. Feel too hot. The nurse in charge will immediately contact the facility administrator so this issue can be addressed immediately.
- All hot water temperature logs will be reviewed daily by the Facility administrator/Designee in the morning meeting to validate facility remains in compliance and no residents are affected related to water temperatures being too hot.
- If at any time during hot water temperature monitoring, any temperature reading is above 110 degrees, the hot water will be shut off to all resident rooms and shower rooms, a plumbing company will be notified to address the issue, and the facility will then monitor hot water temps. Again, every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water temp. testing.
- The Plumbing Service arrived to correct hot water temperatures.
- The facility conducted an Ad Hoc meeting to include the medical director regarding hot water temp. issues identified, including an action plan.
- The facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Hot Water Temps. and reviewed a plan to sustain compliance.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by state licensing requirements. The Activity Director (AD) who took the position on January 27, 2025, did not have evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional. The AD was new to the facility and had not yet received her certification, although she was working towards it. The AD had previously worked as an assistant AD at a sister facility. The Administrator (ADMN) acknowledged the expectation for a licensed Activity Director and admitted responsibility for ensuring the AD was certified. Despite the lack of certification, the ADMN believed there was no effect on residents due to the AD's previous experience and good rapport with residents. The ADMN explained that the hiring decision was made because the AD was the best candidate among applicants, none of whom were certified. The facility's job description for the Activity Director required a degree and license in recreation therapy or equivalent experience and completion of a state-approved course, which the current AD did not meet.
Failure to Conduct Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that physician visits were conducted within the required timeframes for three residents. Specifically, the facility did not have a physician see Resident #22, Resident #23, and Resident #50 within 2-7 days of readmission and once every 30 calendar days for the first 90 days. This deficiency was identified through interviews and record reviews, revealing that the necessary physician visits were not documented in the residents' progress notes. Resident #22, a female with multiple medical diagnoses including Alzheimer's disease, COPD, and type 2 diabetes, was not seen by a physician within the required timeframe after her readmission. Her comprehensive care plan highlighted the need for monitoring and reporting changes in cognitive function, depression, and diabetes management. However, the lack of timely physician visits could have impacted her health status, as there were no physician visits noted in her progress notes. Similarly, Resident #23, who has medical conditions such as muscle weakness, insomnia, and diabetes, and Resident #50, who has cognitive communication deficits and dementia, also did not receive timely physician visits. The facility's failure to adhere to the policy of ensuring physician supervision of resident care was attributed to staffing changes and inadequate monitoring of physician visits by the Medical Records staff and the DON. This oversight could potentially lead to residents not receiving the necessary medical care.
Failure to Adhere to Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The Dietary Aide (DA) entered and exited the kitchen without wearing a beard cover, which is a violation of hygiene practices. This oversight was acknowledged by the DA, who attributed it to being in a hurry. Additionally, the Certified Nursing Assistant (CNA-C) and the Activities Director (AD) did not perform hand hygiene while passing food trays to residents in the hallway. The CNA-C admitted to not sanitizing hands between serving residents and had no justification for this lapse. The AD, who was new to the facility, also failed to perform hand hygiene and had not completed her infection control training. Interviews with the Dietary Manager (DM) and the Director of Nursing (DON) revealed that the facility's staff did not follow infection control practices as trained. The DM stated that the DA should have used a beard restraint, and the DON emphasized the importance of hand hygiene between serving residents. The facility's policy, based on the Hazard Analysis Critical Control Point (HACCP) Plan, outlines the necessity of safe food handling practices to prevent foodborne illnesses. The FDA Food Code also mandates the use of hair restraints in food service areas. The failure to comply with these standards could lead to cross-contamination and potential health risks for residents.
Inadequate Surety Bond for Residents' Trust Funds
Penalty
Summary
The facility failed to purchase a sufficient surety bond to cover the total amount of residents' personal funds deposited with the facility. The surety bond amount was $30,000, which was inadequate to cover the average balance of $32,266.35 in the residents' trust fund account. This discrepancy was identified during a record review of the facility's Bond Execution Report and Bank Account Statistics Report. The facility's policy requires that the surety bond must equal the average monthly balance of all residents' trust fund accounts for the 12-month period preceding the bond issuance or renewal dates. During an interview, the Administrator (ADM) was unable to explain why the surety bond amount was less than the average balance reported. The ADM speculated that the discrepancy might be due to the transition to Deluxe Health Care as a consultant or an increase in the facility's census. Despite the deficiency, the ADM expressed the belief that this issue did not affect the residents in any way. The facility's policy mandates that the trust fund account must be an interest-bearing account, separate from any of the facility's other accounts, and identified as a Resident's Trust Fund Account.
Failure to Obtain Informed Consent for Memory Care Unit Admission
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment, specifically for a resident admitted to the Memory Care Unit (MCU) without obtaining a signed consent. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, a female with multiple medical diagnoses including dementia and cognitive communication deficit, was admitted to the secured unit for specialized dementia care without a documented consent from either the resident or her representative. The absence of a signed consent was confirmed by the Human Resources representative and the Director of Nursing (DON), who acknowledged that it was protocol for all MCU residents to have a signed consent on file prior to admission. Interviews with facility staff revealed that the failure to obtain consent was due to personnel changes and inconsistencies in the admission process. The DON and the Resident Nurse Coordinator (RNC) both indicated that the responsibility for ensuring consents were signed fell on the Admission Coordinator and Medical Records staff, positions that were not consistently filled at the time. The Administrator also acknowledged the protocol breach but noted that the resident's family had requested her placement in the MCU. The facility's policy required a Secure Continuous Care Unit Acknowledgement Form to be signed for admission, which was not completed in this case, potentially impacting the resident's rights.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement to ensure effective and person-centered care. This deficiency was identified for a resident who was admitted with multiple medical diagnoses, including COPD, alcohol dependence, nicotine dependence, chronic pain, respiratory failure, and homelessness. The resident was cognitively intact, as indicated by a BIMS score of 15. The baseline care plan for this resident was not completed until several days after admission, which was beyond the required timeframe. The Director of Nursing (DON) acknowledged the failure to complete the baseline care plan within the 48-hour requirement, attributing the oversight to the resident's admission occurring on a Friday evening. The DON admitted that this delay could have resulted in the resident's care needs not being met in a timely manner. The facility's policy mandates that baseline care plans be developed and implemented within 48 hours of a new admission, but this was not adhered to in this instance.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in permanently affixed compartments during a medication storage inspection. Specifically, medication cart #1 was found unattended and unlocked, with the drawers facing outward, allowing easy access to the medications inside. This incident occurred when RN B, who was responsible for the cart, was in the dining room assisting residents with their meals, leaving the cart unsecured. RN A, upon noticing the unlocked cart, confirmed that it should not have been left in such a state and proceeded to lock it. Interviews with the Director of Nursing (DON) and RN B revealed that the expectation was for medication carts to be locked when not in use. The DON acknowledged that the failure to secure the cart was due to RN B being distracted and forgetting to lock it. RN B admitted to being aware of the policy requiring carts to be locked and stated that she had been trained accordingly. The medications on the cart included cardiac medications, blood pressure medications, over-the-counter medications, stool softeners, vitamins, eye drops, and inhalers, but no insulin. The facility's policy mandates that all drugs and biologicals be stored in locked compartments to ensure security and prevent unauthorized access.
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What surveyors actually found near you
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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.
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Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wisteria Place | 2.5 mi | ★★★★★ | 5 | 1 |
| Avir At Coronado | 3 mi | ★★★★★ | 28 | 0 |
| Northern Oaks Living & Rehabilitation Center | 3.5 mi | ★★★★★ | 9 | 0 |
| Hendrick Skilled Nursing Facility | 3.7 mi | ★★★★★ | 1 | 0 |
| The Oaks At Radford Hills Healthcare Center | 4.2 mi | ★★★★★ | 12 | 0 |
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