Willowcreek Wellness & Rehabilitation
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
must start the whole process of contacting the physician again to get the script over or the pharmacy does not immediately send the medication over. The resident gets upset and immediately calls 911. He/She does not want any other interventions. During an interview on 10/29/25 at 12:15 P.M., the Assistant Director of Nursing said staff should order the medication a few days before it runs out. The resident takes so much medication, a card of 30 runs out very quickly. The pharmacy wants a new script when they get a new order. The medication they carry in the e-kit is not the same dosage the resident is prescribed, so they have to contact the physician and get an order for the different dosage before the pharmacy will okay it from the e-kit. All of this takes time, and sometimes the resident runs out of the medication before they can get it filled. The staff have offered the resident other non-pharmacological interventions, but he/she will not accept them. He/She is not receptive to taking non-opioid pain relievers. During an interview on 10/29/25 at 11:30 A.M., the Director of Nursing said staff should call the pharmacy and order the medication several days before it runs out so the resident does not go without it. The staff can also check the e-kit and pull the medication from there if they have it, to hold the resident over until the medication arrives from the pharmacy. The resident calls 911 because he/she believes he/she will get a higher dosage of the medication at the hospital. There have been times when he/she called 911 even after receiving his/her medication. The EMS personnel are familiar with him/her. He/She refuses all non-pharmacological interventions like position changing, heat and non-opioid medications. Review of an email sent from the DON on 11/3/25 at 11:30 A.M., showed the resident attended his/her pain clinic appointments in May and June for imaging and injections but refused later appointments, preferring to adhere to his/her current oxycodone pain management as he/she liked this regimen the best. They spoke to the resident and he/she agreed to go and they scheduled an appointment for 12/1/25. During an interview on 10/29/25 at 1:30 P.M.,
the Administrator said the resident should get his/her medication as ordered. He/She should not be in pain for hours because the medication was unavailable. She expected staff to order it before it ran out or pull it from the e-kit if it did not arrive on time. During an interview on 10/31/25 at 9:30 A.M., the resident's physician said the resident should not go without his/her pain medication, but there is an issue with the facility staff and the pharmacy. The facility staff should order the medication on time. The pharmacy should fill it on time. They want a script every time and this takes time to call the physician and get one sent over.
He thinks the resident is drug seeking and should see a pain specialist, but the resident has refused to see one in the past. He did not know if anyone approached the resident recently to suggest this again, but they should try to get him/her to go see one. 2646728
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowcreek Wellness & Rehabilitation
250 New Florissant Road South Florissant, MO 63031
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0740
F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident signed out around 9:00 A.M., to go to the store. He/She did not return by lunch time. A CNA went to the store to check on the resident. The resident was still at the store. The resident did not return later. The DON directed the nurse to contact law enforcement to obtain his/her location via his/her ankle monitor. At 11:17 P.M., the nurse called and spoke with resident's family member. The family member said the resident was ok and he/she was unsure if the resident would return to the facility tonight. The nurse informed the family member the resident needed to return before midnight;-On [DATE REDACTED] at 10:18 A.M., the resident remained on LOA;-On [DATE REDACTED] at 9:00 P.M., the resident returned to the facility via EMS from the hospital, with a diagnosis of vomiting/nausea and dehydration. The physician was notified. The resident was readmitted to the facility. Review of the Social Services notes, dated [DATE REDACTED] at 6:35 P.M., showed the SSD noted the resident was admitted to the facility from the hospital, he/she was shot in the back by someone he/she knew. He/She was released on bond and had an ankle monitor. He/She agreed to meet with a behavioral health counselor. The resident rights, and drug and alcohol policy were reviewed with the resident. He/She scored a 15 (cognitively intact)on the brief interview for mental status (BIMS, a standardized assessment tool to screen cognitive functioning) assessment. Review of the resident's admission MDS, dated [DATE REDACTED], showed: -admitted [DATE REDACTED];-Cognitively intact;-No behaviors exhibited;-Diagnoses included paraplegia (spinal cord injury) and psychoactive substance abuse (the harmful or excessive use of substances that alter brain function and produce psychological effects). Review of the resident's care plan, in use during the survey, showed:-Problem: The resident had a psychosocial well-being problem due to pain, recent admission, mood, and psychoactive substance abuse (Date Initiated: [DATE REDACTED])-Goal: He/She will demonstrate adjustm[TRUNCATED]
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WILLOWCREEK WELLNESS & REHABILITATION in FLORISSANT, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLORISSANT, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOWCREEK WELLNESS & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.