🔎 Willow Creek Healthcare Center
Inspection Results
Inspection Overview
Willow Creek Healthcare Center has been cited for a total of 75 deficiencies since we began saving each survey.
In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Scope/Severity: E
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.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
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.
Scope/Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Dispose of garbage and refuse properly.
Scope/Severity: D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Scope/Severity: E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Dispose of garbage and refuse properly.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: G
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: L
Provide and implement an infection prevention and control program.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
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.
Scope/Severity: E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: H
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: H
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity: D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Scope/Severity: D
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.
Scope/Severity: D
Provide or obtain dental services for each resident.
Scope/Severity: E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Scope/Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity: D
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: E
Keep all essential equipment working safely.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
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.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
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.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Keep all essential equipment working safely.
Scope/Severity: E
Store, cook, and serve food in a safe and clean way.
Scope/Severity: E
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Scope/Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**