Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbend Health And Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke sustained a dislocated shoulder due to improper transfer by a CNA who failed to use the correct lift and lacked assistance from another staff member. Additionally, hazardous materials were left accessible to residents, violating the facility's accident prevention policy.
The facility failed to accurately document hospice care and dialysis on the MDS for two residents. One resident receiving hospice care was not marked as such in the MDS, and another receiving dialysis was incorrectly documented. The MDS Coordinator confirmed these oversights, highlighting the importance of accurate MDS documentation for resident care.
The facility failed to document person-centered care plans for three residents, omitting necessary interventions for conditions such as COVID-19, ESBL, and upper respiratory infections. The MDS Coordinator and DON confirmed these omissions, acknowledging that changes in condition should be reflected in care plans to guide staff in providing appropriate care.
Surveyors found expired medications in two medication carts, including over-the-counter and a narcotic prescribed to a resident with Parkinson's disease. Despite facility policies for removing expired medications, these were not followed, as confirmed by interviews with nursing staff. The resident involved was at risk for pain, highlighting a lapse in medication management protocols.
The facility did not adhere to the planned menus, affecting the nutritional needs of residents. During meal services, insufficient turkey was prepared for residents on mechanical soft diets, and incorrect portion sizes were served. Additionally, the kitchen ran out of specified menu items, leading to substitutions. At breakfast, residents on pureed diets did not receive the planned items due to staff oversight.
The facility failed to maintain proper food storage and cleanliness standards, with numerous food items not covered, sealed, or dated. Dietary staff did not adhere to proper hand hygiene and glove usage, contaminating food items. Additionally, ice machines were not maintained in a clean condition, with black residue found in areas where ice forms. These deficiencies highlight lapses in food safety and hygiene practices.
A facility failed to complete a PASARR prior to the admission of a resident with cognitive impairment and psychiatric diagnoses. The required documentation was missing from the resident's records, and staff confirmed its absence. A PASARR was only provided after a surveyor's request, dated post-admission.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident during a transfer, resulting in a dislocated right shoulder. The incident involved a resident with a history of stroke and severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The resident's care plan specified the use of a mechanical lift with two staff members assisting for transfers. However, during the transfer, a CNA used a sit-to-stand lift instead of the required mechanical lift and did not have the assistance of another staff member, leading to the resident's injury. The incident occurred when the resident began to complain of pain in their right arm during the transfer. A second CNA responded to the call for help and assisted in lowering the resident to the floor to prevent a fall. Despite the intervention, the resident was lifted improperly by the CNAs, which contributed to the dislocation of the shoulder. The resident was subsequently assessed by an RN, who arranged for a mobile x-ray and coordinated with the Medical Director to send the resident to the emergency room for further evaluation. Additionally, the facility was cited for failing to prevent access to hazardous materials, such as aerosols, medications, and creams, which were left unattended and accessible to residents. This was observed when a CNA left a clear plastic bag containing these items on a counter at wheelchair height, posing a risk to residents who wander the halls. The facility's policy on accident hazards prevention was not adhered to, as these items should have been stored out of reach and behind closed doors to prevent accidental exposure or injury.
Inaccurate MDS Documentation for Hospice and Dialysis
Penalty
Summary
The facility failed to accurately document hospice care and dialysis services on the Minimum Data Set (MDS) for two residents. Resident #75, who was admitted with diagnoses including dementia and reduced mobility, was also under hospice care due to a prognosis of a life expectancy of six months or less. Despite this, the hospice care was not marked in Section O of the MDS. The MDS Coordinator confirmed the oversight during an interview, acknowledging that the resident was indeed on hospice care and should have been marked accordingly. Similarly, Resident #34, who was receiving dialysis three times a week, was not accurately documented in the MDS under Section O for dialysis. The MDS Coordinator confirmed that dialysis should have been marked as 'yes' but was incorrectly marked as 'no'. The Director of Nursing emphasized the importance of a correct MDS to ensure proper care for the residents.
Failure to Document Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to document and complete person-centered care plans for three residents, leading to deficiencies in planning and providing necessary care and services. Resident #104, admitted with hyperlipidemia and COVID-19, did not have person-centered activities or COVID-19 isolation precautions included in their care plan. Despite having an order for airborne isolation due to COVID-19, these interventions were not documented in the care plan. The MDS Coordinator confirmed that these elements should have been included. Resident #107, diagnosed with dementia and severely cognitively impaired, tested positive for ESBL in the urine, but the care plan lacked person-centered interventions for ESBL and contact precautions. Similarly, Resident #92, with chronic respiratory conditions, was on antibiotics for an upper respiratory infection, yet the care plan did not include interventions for this condition. The MDS Coordinator and the DON acknowledged that these omissions were oversights, as changes in condition should be reflected in the care plans to guide staff in providing appropriate care.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to ensure that medications, including over-the-counter and narcotic medications, stored in medication carts were not expired. During an inspection of two medication carts, surveyors found a total of 13 expired medications. These included various over-the-counter medications such as antacids, stool softeners, nutritional drinks, and pain relievers, as well as a narcotic medication prescribed to a resident with Parkinson's disease. The facility's policy on medication storage, dated January 1, 2015, requires that all expired medications be removed from active supply and destroyed. However, the survey revealed that expired medications were still present in the medication carts. Interviews with nursing staff, including registered nurses and the Assistant Director of Nursing (ADON), confirmed that there were procedures in place for handling expired and discontinued medications, but these procedures were not effectively implemented, as evidenced by the presence of expired medications in the carts. The resident involved, who was prescribed the expired narcotic medication, had a history of Parkinson's disease and was at risk for pain, as noted in their care plan. Despite the facility's policy and procedures for medication management, the failure to remove expired medications from the carts indicates a lapse in adherence to these protocols, potentially impacting the quality of care provided to the residents.
Failure to Follow Planned Menus and Meet Nutritional Needs
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which compromised the nutritional needs of the residents. During the observation of the supper meal preparation and service, it was noted that the turkey meat prepared for residents on mechanical soft diets was insufficient. The dietary staff weighed and prepared only 28 ounces of turkey for 21 residents, instead of the required 84 ounces. Additionally, the staff used a #12 scoop to serve 3 ounces of ground turkey instead of the specified 4 ounces. Furthermore, the kitchen ran out of stuffing and broccoli, leading to the use of a smaller scoop for stuffing and the substitution of green beans for broccoli, which did not align with the menu specifications. The deficiency continued during the breakfast meal service, where residents on pureed diets did not receive the specified pureed hash browns and pureed biscuits. The dietary staff admitted to forgetting to serve these items, which were part of the planned menu for residents requiring pureed diets. These actions and inactions resulted in the facility not meeting the nutritional needs of the residents as outlined in the planned menus, affecting the quality of care provided to the residents.
Deficiencies in Food Storage, Hygiene, and Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain proper food storage and cleanliness standards in the kitchen and food preparation areas. Observations revealed numerous food items in the refrigerator, freezer, and storage room that were not covered, sealed, or dated, including marshmallows, pasta, hash brown patties, beef franks, ice cream, tomatoes, scrambled eggs, buttermilk, raw chicken, bologna, cucumber and onion mix, shredded lettuce, coleslaw, and a flavored drink mix. Additionally, the grease drip pan and stove top were not cleaned as required, and the spice shelf contained a bag of grits with no date. The facility also failed to ensure proper hand hygiene and glove usage among dietary staff. Instances were observed where dietary staff did not change gloves or wash hands after handling dirty objects and before handling food items. This included using a dirty spoon to scoop food, handling a blender motor without changing gloves, and picking up condiments and beverages with bare hands, contaminating them before serving to residents. Furthermore, the facility did not maintain the ice machines in a clean and sanitary condition. Both the kitchen and nourishment room ice machines had black residue buildup, which was easily wiped off with tissue paper. The residue was found in areas where ice forms and drops into the collector, and the ice from these machines was used for resident beverages and in resident rooms. The facility's policy on handwashing and glove usage was not adhered to, contributing to the deficiencies observed.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to the admission of a resident, which is necessary to ensure the resident receives the needed care and services in the most appropriate setting. The resident in question, identified as having a moderately cognitive impairment with a BIMS score of 10, was diagnosed with a psychotic disorder and non-Alzheimer's dementia. Upon review, the resident's electronic medical record did not contain the required PASARR documentation. Interviews with the Social Director and the Director of Nursing confirmed the absence of the PASARR in the resident's chart or facility records. A PASARR was only provided after the surveyor's request, dated after the resident's admission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Broadway | 3.8 mi | ★★★★★ | 1 | 0 |
| The Springs Of Avalon | 4.4 mi | ★★★★★ | 0 | 0 |
| Regional One Health Subacute Care | 9.7 mi | — | 0 | 0 |
| Harborview Post Acute | 10.5 mi | ★★★★★ | 7 | 0 |
| Midtown Center For Health And Rehabilitation | 12.7 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.