Valencia at Willow Creek

August 27, 2025 · Follow-Up Inspection

No citations from this inspection.

June 25, 2025 · Follow-Up Inspection

• Moderate Material stored in locked area(R432-270-23(5))

  The provider was out of compliance with R432-270-23(5) by not ensuring cleaning agents and poisonous and dangerous materials were stored in a locked area to prevent unauthorized access. During the inspection, the licensor observed that a container with bleach wipes and a disinfectant spray was accessible to the residents of the memory care unit. This is a repeat non-compliance from the inspections dated September 3, 2024, November 20, 2024, and April 23, 2025.

  How was this corrected? The licensor verified that the unsecured chemicals had been removed and that the locking mechanism on the cupboard had been repaired.

  Corrected on June 25, 2025. The state accepted it without a return visit.

• Low Written schedule for maintenance(R432-270-25(1))

  The provider was out of compliance with R432-270-25(1) by not ensuring that maintenance was conducted to ensure that the facility spaces were safe, operable, in good repair, and in compliance with R432-6. During the inspection, the licensor observed that multiple fire doors throughout the facility did not close and latch securely upon being tested. This is a repeat non-compliance from the inspection dated September 3, 2024 and April 23, 2025.

  How was this corrected? On August 27, 2025, the licensor verified that the fire doors throughout the facility closed and latched securely, as required in rule.

  Corrected on August 27, 2025, verified by the state.

April 23, 2025 · Complaint, Investigation Inspection

• High Written schedule for maintenance(R432-270-25(1))

  The provider was out of compliance with R432-270-25(1) by not ensuring all facility spaces were safe, in good repair, and in compliance with Rule R432-6. During the inspection, the licensor observed that 2 doors in the secure unit did not automatically close and latch securely without physical intervention upon being tested. Additionally, 1 resident was identified as having eloped from the secure unit by exiting one of the malfunctioning doors one month before the investigation.

  How was this corrected? On August 27, 2025, the licensor verified that the fire doors throughout the facility closed and latched securely, as required in rule.

  Corrected on August 27, 2025, verified by the state. · $200 penalty

• Moderate Material stored in locked area(R432-270-23(5))

  The provider was out of compliance with R432-270-23(5) by not ensuring cleaning agents and poisonous and dangerous materials were stored in a locked area to prevent unauthorized access. During the inspection, the licensor observed that laundry detergent was accessible to the memory care residents. Additionally, other unsecured chemicals were observed to be accessible to non-memory care residents. This is a repeat non-compliance from the inspections dated September 3, 2024 and November 20, 2024.

  How was this corrected? On June 25, 2025, the licensor verified that the Administrator had removed the unsecured chemicals and that the locking mechanism in the memory care unit had been repaired to prevent unauthorized access, as stated in rule.

  Corrected on June 25, 2025, verified by the state.

• Low Resident Assessment used for Service Plan(R432-270-14(2))

  The provider was out of compliance with R432-270-14(2) by not ensuring the resident assessment was used to develop, review, and revise the service plan for each resident. During the inspection, the licensor reviewed resident assessments and service plans and determined that they were not used to develop, review, and revise the service plans for 3 residents. This is a repeat non-compliance for the inspection dated September 3, 2024.

  How was this corrected? On June 25, 2025, the licensor verified, through a record review, that resident assessments were used to develop, review, and revise the service plan for each resident

  Corrected on June 25, 2025, verified by the state.

• High Type II accept and retain residents(R432-270-11(5)(a-c))

  The provider was out of compliance with R432-270-11(5)(a)(ii) by not ensuring the licensee accepted and retained residents who were capable of evacuating the facility with the limited assistance of one person. During the inspection, the Licensor identified 1 resident who required more than the limited assistance of one person to evacuate the facility.

  How was this corrected? On June 25, 2025, the licensor verified that the facility did not accept and retain non-hospice residents who required more than the limited assistance of one person to evacuate the facility, as stated in rule.

  Corrected on June 25, 2025, verified by the state. · $200 penalty

• Low Resident unable to self administer medications(R432-270-19(7)(a)-(f))

  The provider was out of compliance with R432-270-19(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, 1 resident was identified as not having received their medications due to the medication's unavailability. This is a repeat non-compliance from the inspections dated September 3, 2024 and November 20, 2024.

  How was this corrected? On June 25, 2025, the licensor verified that resident medications were administered according to physician orders, as stated in rule.

  Corrected on June 25, 2025, verified by the state.

• Low Written schedule for maintenance(R432-270-25(1))

  The provider was out of compliance with R432-270-25(1) by not ensuring that maintenance was conducted to ensure that the facility spaces were safe, operable, in good repair, and in compliance with R432-6. During the inspection, the licensor observed that multiple fire doors throughout the facility did not close and latch securely upon being tested. This is a repeat non-compliance from the inspection dated September 3, 2024.

  How was this corrected? On June 25, 2025, the licensor verified that the two magnetic doors in the memory care unit closed without physical assistance. Both doors closed and locked as required in rule.

  Corrected on June 25, 2025, verified by the state.

December 12, 2024 · Follow-Up, Additional Follow-Up Inspection

No citations from this inspection.

November 20, 2024 · Follow-Up Inspection

No citations from this inspection.

September 3, 2024 · Unannounced, Annual Inspection

• High Type II Hospice Patients(R432-270-11(10)(a)-(c))

  The provider was out of compliance with this rule by not ensuring that hospice services were part of the resident's service plan that explained who was responsible to meet the resident's needs. In addition, residents on hospice, who could not evacuate the facility without significant assistance in an emergency, did not have an evacuation plan developed. During the inspection, the licensor reviewed 2 hospice residents medical files that did not include a copy of the hospice orders for care, evacuation plans for resident who could not evacuate without significant assistance, and a service plan for a resident that did not incorporate hospice services into the plan.

  How was this corrected? On 11/20/2024, the licensor verified that hospice services were part of the resident's service plan that explained who was responsible to meet the resident's needs. In addition, residents on hospice, who could not evacuate the facility without significant assistance in an emergency, and had an evacuation plan developed, as stated in rule.

  Corrected on November 20, 2024, verified by the state. · $200 penalty

January 23, 2024 · Complaint, Investigation Inspection

• High Update Status within 5 working days(R432-35-4(3))

  The provider was out of compliance with this rule by not ensuring that each covered individual was connected to the facility in DACS within 5 working days of engagement. During the inspection, 3 employees current status was not reflected in DACS within 5 working days of engagement or termination.

  How was this corrected? On 2/7/2024, the licensor verified that the Administrator updated the current status of covered individuals in the Direct Access Clearance System within 5 working days of engagement or termination, as stated by rule.

  Corrected on February 7, 2024, verified by the state. · $200 penalty