Willow Wood Care Center

To ensure nursing home residents remain safe in their environment, the Centers for Medicare and Medicaid Services (CMS), and the state of Utah conduct routinely scheduled surveys and unannounced inspections of every nursing facility under their jurisdiction. These extensive surveys help inspectors identify minor to serious infractions and violations. After performing observations and conducting interviews, the state and federal nursing agencies notify the facility of all acknowledged deficiencies to ensure these problems are quickly corrected. The corrections and adjustments might involve revising ineffective policies and procedures or the need to provide additional training to the nursing staff.

In some cases, deficiencies are the result of serious underlying problems that require extensive improvements and ongoing inspections. If the nursing home is unable or unwilling to make necessary adjustments and needed improvements, the Home may be placed on the Special Focus Facility (SFF) list. The SFF designation helps a public identify a nursing facility in their community that has provided substandard care to their residents.

Recently, Willow Wood Care Center was designated a Special Focus Facility by CMS and Utah state regulators. The facility has the opportunity to make corrections immediately to maintain the health and well-being of every resident under their care. Likely, the facility will remain on the federal watch list for years and must undergo numerous additional scheduled surveys and unannounced inspections to ensure that the positive corrections they make are long-lasting.

Willow Wood Care Center (SFF)

The 77-certified bed Medicare/Medicaid-participating nursing facility provides cares and services to the residents of Salt Lake City and Salt Lake County, Utah. The facility is located at:

1205 E. 4725 South
Salt Lake City, UT 84117
(801) 262-2908


Regulators for the Centers for Medicare and Medicaid Services and the state of Utah can issue fines against nursing facilities with identified egregious violations and serious deficiencies. On March 23, 2016, Willow Wood Care Center received a $125,000 fine. Nursing home regulators also denied numerous payments for Medicare services on March 23, 2016, and again on June 26, 2017. There were multiple formal complaints issued against the facility that resulted in five citations in the past three years.

Current Nursing Home Resident Safety Concerns

To ensure the public remains fully informed of the level of care that every nursing facility provides in the United States, the CMS and state regulatory agencies routinely update their nursing home database. This information is posted on the federal Medicare.gov website as a star rating summary system.

Currently, Willow Wood Care Center maintains a below-average overall two out of five stars rating compared although the facilities in the US. This ranking includes one out of five stars for health inspections, one out of five stars for staffing, and five out of five stars for quality measures. Some of the serious violations and deficiencies are listed below.

  • Failure to Provide Proper Treatment to Prevent the Development of a Bedsore or Allow an Existing Bedsore to Heal

    In a summary statement of deficiencies dated June 26, 2017, the state investigator noted the facility’s failure “to provide care to prevent the development of a pressure ulcer. Specifically, two residents who were admitted to the facility without a pressure ulcer developed a pressure ulcer [while] in the facility. These findings were found to have occurred at a harm level.”

    In one incident, a resident’s 5:40 PM April 2, 2017, Nursing Progress Notes revealed “no skin issues noted at this time.” By the afternoon of April 23, 2017, records documented that the resident “has a purple spot on her buttocks” which was treated by cleansing the buttocks area, using wound cleaner, allowing it to dry, and applying Hydrocolloid dressing as needed.

    By June 10, 2017, the resident was noted as having a “deep tissue injury on the buttocks and is turned every two hours and treated in place.” Three days later, the resident received an order “to obtain a low airflow mattress” on June 13, 2017, where the staff was ordered to “monitor and assess effectiveness.”

    The history of the wound is documented as no skin integrity problems on May 3, 2017, and by May 17, 2017, there was a documented skin “break; buttocks. No measurements or assessments of the pressure ulcer were documented.” A week later on May 24, 2017, the weekly skin check documented a continued “breakdown on the buttocks.” However, there was “no measurements or assessments of the pressure ulcer documented.” Again, on May 31, 2017, the weekly skin check “documented skin breakdown” but again “no measurements or assessments of the pressure ulcer were documented.” Even after the wound had opened on June 14, 2017, “no measurements or assessments of the pressure ulcer were documented.”

    The state investigator interviewed the facility’s Director of Nursing on the afternoon of June 26, 2017, who stated that “the facility had not been tracking redness and Stage II pressure ulcers as part of a program to ensure that [the] appropriate treatments are in place to prevent the ulcers from worsening.” The Director confirmed that the facility’s Register Dietitian “did not attend the skin and weight meeting, nor did she review the notes and recommendations made.” The Director also stated that “she did not notify the Register Dietitian of any significant way changes or changes in the skin because the [dietitian’s] responsibility was only to do quarterly notes for everyone.”

  • Failure to Provide an Environment Free from Accident Hazards

    In a summary statement of deficiencies dated June 26, 2017, the state investigator noted the facility “did not provide adequate supervision and assistance devices to prevent accidents for [three residents].” It was also noted the facility “did not ensure that the resident environment remained as free from accident hazards as possible. Specifically, resident was observed to be touching another resident inappropriately, one resident had multiple falls without timely interventions, and observations of unattended razor blades were made.”

    The surveyor observed a resident at the facility at 2:55 PM on June 21, 2017 “Wheeling himself in his wheelchair from the hallway into [another resident’s] room. The visiting resident “was observed opening closets in the room and then turned his wheelchair around and wheeled toward [the female resident] who was sitting on the side of her bed.” The male resident in his wheelchair “began holding the [female resident’s] hand and then started to rub [her] right knee.”

    The male resident “then began rubbing [the female resident’s] right inner thigh, about three-quarters of the way up her right inner thigh.” The male resident “then rubbed [the female resident’s] left knee and left arm and shoulder [before holding the female resident’s] left hand and helped her out of bed.” At this point, the facility’s Wound Nurse “entered the room, separated the two residents and had [the male resident] removed from the room.”

    The state investigator interviewed the facility’s Certify Nursing Assistant (CNA) on the morning of June 21, 2017, concerning the male resident’s sexual behaviors. The CNA stated that “there was a little bit of touching by the [male resident] when he first arrived at the facility, like trying to hold hands.” The CNS continued that there was “no other sexual behavior over the last two weeks [and that the] resident stayed in his wheelchair, which made it harder for him to get around the unit.”

    A few minutes later, the Wound Nurse was interviewed concerning the resident’s sexual behaviors. The nurse stated that “there had not been any inappropriate sexual behavior since the resident’s admission [but that the male resident] would hover outside people’s rooms; however, the facility staff would remind the resident that this was not his room and redirect him.”

    Other Certified Nursing Aides were also interviewed. One stated that “the resident liked to touch the women on their hands and arms and go into the rooms sometimes. However, he was redirected by facility staff right away. On the morning of June 22, 2017, the facility’s Administrator “informed the survey team that [the male resident] was put on a one-to-one level of observation for the [previous] evening and night shift. He stated that the resident was going to be transferred to a local behavioral hospital so that a psychiatric evaluation could be done due to a change in the resident’s condition.”

    In a separate incident, the state investigator observed a violation on the early morning of June 19, 2017, in “the West Hallway communal shower room [where] the shower room door was pushed open, and the shower was occupied. Upon inspection of the shower room, it was noted that a razor blade and a can of shaving cream were located on the sink.”

    Thirty-five minutes later, an observation was made at the East Hallway Nurses’ Station, which is located within the locked memory care unit. The Nurses’ Station contained a white storage cabinet with a childproof lock on the handles. The cabinet contained disposable razors. The childproof latch was observed to be easily opened by pulling on it. At the time of the observation, [a resident] was observed to be wandering the hallways in an out of the Nurses’ Station.”

    The surveyor interviewed the facility Director of Nursing on the late morning of June 21, 2017, who stated that “the resident population with more progressive dementia and wandering tenancies or increased behaviors reside in the Memory Care Unit.” The Director also stated that “on the West Wing, which was unlocked, the resident population also included residents with dementia and cognitive impairments [and that] the staff was supposed to discard all use razors in the Sharp’s container, and that the razors should never be left unattended.”

  • Failure to Ensure That Every Resident’s Medication Regiment Is Free from Unnecessary Drugs

    In a summary statement of deficiencies dated June 26, 2017, the state investigator noted the facility’s failure to ensure a “resident’s drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose, for an excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences which indicate that the dose should be reduced or discontinued.”

    Specifically, the state investigator was concerned over [a resident’s] anti-anxiety, antipsychotic, and an antidepressant were administered to a resident without appropriate monitoring of behaviors.”

  • Failure to Ensure That Residents Remained Safe from Serious Medication Errors

    In a summary statement of deficiencies dated June 26, 2017, the state investigator noted that the facility “did not follow orders for an increase in the prescribed anticoagulant, placing the resident at risk related to their clinical conditions and abnormal coagulation profile.” It was also noted that the staff “did not administer an anticonvulsant on multiple occasions, placing the resident at risk for [an unexpected reaction].”

    After reviewing the resident’s Medication Administration Records, the State surveyor interviewed the facility’s Director Nursing on the morning of June 26, 2017 “regarding the delay in administering the increased dose of [the resident’s medication].” The Director “confirmed that the order should have been followed on the same day of May 18, 2017.” The Director also stated that on one occasion the resident did not receive their medication because they were asleep.

    Both the facility Administrator and Director of Nursing were asked on the morning of June 26, 2017, if “the physician was ever asked about changing the timing of the medication since there were multiple times the medication was not administered due to the resident sleeping.” The Director responded that “the physician had not been asked about changing the timing the resident’s medication.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infections from Spreading

    In a summary statement of deficiencies dated June 26, 2017, the investigator stated that the facility “did not establish an effective infection prevention and control program that included providing services that followed acceptable national standards to prevent the spread of infections.”

    Specifically, the state investigator was concerned about “one staff member was observed to cross-contaminate sterile equipment during a dressing change.” An observation was made of the facility’s Wound Nurse on the afternoon of June 22, 2017, while “changing [a resident’s] coccyx pressure ulcer dressing. The Wound Nurse was observed washing hands prior to the treatment, and new gloves were applied.

    The state investigator observed “with her right hand the Wound Nurse removed the old dressing dated June 21, 2017” and performed care that broke the sterile barrier and caused the potential cross-contamination and exposure to infection. An interview with the Director of Nursing on the afternoon of June 22, 2017, revealed that “the expectation of the nursing staff during dressing changes is that they do not cross contaminate.”

Were You Abused or Mistreated in a Nursing Home?

If you, or a loved one, were abused, neglected or mistreated while residing in a nursing facility, you are likely entitled to seek justice and obtain financial compensation for your injuries caused by the negligence of the nursing staff. Consider hiring a personal injury attorney who specializes in neglect and abuse cases. Legal representation by a law firm can help secure your family’s right to recompense from those who caused your harm.

It is important to file your compensation claim quickly before the statute of limitations expires. An attorney can handle every aspect of your case and is paid after the claim is successfully resolved in court or through a negotiated out of court settlement.


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