Care Citations

WILLOW CREEK HEALTHCARE CENTER

650 W. ALLUVIAL, CLOVIS, CA, 93611 · 5593236200

Legal business name: WILLOW CREEK POST ACUTE, LLC

On the CMS record

Overall rating (CMS)
3 / 5
Health inspection rating
2 / 5
Staffing rating
3 / 5
Certified beds
159
Ownership type
For profit - Limited Liability company
Chain
PACS GROUP

Inspection findings on record (62)

Quoted exactly as CMS published them. We do not rewrite findings.

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity G · actual harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity G · actual harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity E · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0814 · scope/severity E · potential for more than minimal harm

Dispose of garbage and refuse properly.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0557 · scope/severity D · potential for more than minimal harm

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0919 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Environmental Deficiencies

Tag 0919 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity G · actual harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0700 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0814 · scope/severity F · potential for more than minimal harm

Dispose of garbage and refuse properly.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity D · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity H · actual harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity H · actual harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity E · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0802 · scope/severity E · potential for more than minimal harm

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity E · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0908 · scope/severity E · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0583 · scope/severity D · potential for more than minimal harm

Keep residents' personal and medical records private and confidential.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity D · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0700 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0711 · scope/severity D · potential for more than minimal harm

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0791 · scope/severity D · potential for more than minimal harm

Provide or obtain dental services for each resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0808 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 555652