Willow Creek Lodge

Inspection findings

1. Nov 19, 2025 Health · 1 finding
   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Nov 20, 2025 · CMS health inspection

2. Jul 17, 2025 Health · 15 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0742 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Aug 29, 2025 · CMS fire safety

3. Jul 2, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jul 25, 2025 · CMS health inspection

4. Jun 13, 2024 Health · 6 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0710 Nursing and Physician Services Deficiencies

     Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 18, 2024 · CMS fire safety

5. Sep 20, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0622 Resident Rights Deficiencies

     Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

     Corrected Oct 16, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Oct 16, 2023 · CMS health inspection

6. Mar 24, 2023 Health · 8 findings
   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Apr 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Apr 5, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Mar 25, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

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

     Corrected Mar 25, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 25, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0922 Environmental Deficiencies

     Have enough backup water supply for essential areas of the nursing home.

     Corrected Apr 17, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Mar 24, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 24, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• GREWAL, HERMANJEET — adp of the snf, NOT APPLICABLE, since 05/01/2026
• GREWAL, HERMANJEET — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• GREWAL, HERMANJEET — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• JOHN, BIJU — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• JOHN, BIJU — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• JOHN, BIJU — adp of the snf, NOT APPLICABLE, since 05/01/2026
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• MCGUIRE, WESLEY — corporate officer, NOT APPLICABLE, since 05/01/2023
• CANYONLANDS PEAK HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• CANYONLANDS PEAK HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 06/10/2026
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 02/11/2026
• NORTHPOINTE BLVD HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 05/01/2026
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 05/01/2026
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 05/01/2026