Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willows Health Center during CMS and state inspections, most recent first.
An LPN worked on multiple shifts while their nursing license was under suspension, and the facility did not prevent this, affecting all residents present on those days. Facility records showed that the LPN’s license was suspended according to the state licensing agency, yet timesheets confirmed the LPN worked during the suspension period while the census reflected dozens of residents in the building. Human Resources later stated the LPN had not disclosed the suspension and acknowledged that nurses should not work when their licenses are suspended, consistent with state licensing guidance prohibiting practice during a suspension.
A resident admitted with multiple health conditions and requiring maximum assistance developed a new unstageable pressure ulcer on the left heel after admission. Initial skin checks did not reveal any issues, but the ulcer was discovered by staff about a week later. Although the care plan included ace wraps, skin monitoring, and pressure-relieving interventions, the ulcer developed between weekly skin checks, and daily full inspections of the feet may not have been performed.
The facility failed to ensure a safe environment and adequate supervision for two residents at high risk for accidents. A resident with Alzheimer’s disease, dementia, anxiety, weakness, and a prior hip fracture, care planned as high fall risk and requiring extensive ADL assistance and a mechanical lift, was noted by staff to be extremely restless and repeatedly trying to stand from a wheelchair with a quiet chair alarm. She was left unsupervised at the nurses’ station while staff attended to another resident, during which time she fell, was found on the floor with head bleeding and severe right leg pain, and was later diagnosed with an acute displaced right femoral fracture. Another resident with Parkinson’s disease and dementia, whose hospital SLP plan required 1:1 feeding assistance and prohibited straw use due to aspiration risk, was repeatedly observed with cups of liquid and straws at bedside and on meal trays, while staff acknowledged that hospital transfer and SLP recommendations, including no straws, should have been followed.
Surveyors found that food was not stored or handled in a sanitary manner and that cooking areas were not kept clean. An opened box of French baguettes, including an unwrapped baguette, was stored directly under a condenser/evaporator in the walk-in freezer, with ice build-up on the box, contrary to facility policy requiring covered, labeled, and properly contained food. The exhaust hood over the cooking area had visible dust and debris on the fire suppression lines above the cooking surfaces, despite written procedures and maintenance responsibilities for regular cleaning of such equipment.
The facility failed to provide meaningful, individualized activities to multiple residents with dementia, particularly on weekends. Several residents with Alzheimer’s dementia or other cognitive impairments were observed sitting in wheelchairs or recliners in front of the TV, asleep or simply looking around, with no engagement in the structured activities listed on the memory care activity calendar. Some residents’ care plans documented impaired cognitive function/dementia but contained no activity interventions, while another resident’s plan noted dependence on staff for leisure pursuits but individual visits were not observed. An LPN and several CNAs reported there were no activities on weekends in the dementia unit and that they only tried to talk with residents or help with puzzles or reading in between nursing tasks. Leadership staff confirmed there was no activity staff on weekends, despite a facility policy stating that meaningful, ability-centered activities for residents with cognitive or memory diseases are to be continually available.
A resident had a PRN order for sublingual Ativan for anxiety that was entered without a required stop date, contrary to facility policy and regulatory expectations. The Nurse Manager, who oversees psychotropic meds, reported he was unaware the order lacked a stop date and stated the order was carried out by hospice staff and should have been clarified. He later produced a separate document for the antianxiety order that was not present in the resident’s medical record, despite his statement that all psych meds with stop dates should be reflected there.
A resident with Parkinson’s disease, dementia, and an ADL self-care deficit requiring staff assistance was observed to be confused, very restless, and repeatedly stating the need to use the bathroom while partially out of bed. After the call light was activated, a CNA not assigned to the unit entered 12 minutes later, turned off the call light, and left to find the assigned CNA. An RN appeared briefly at the doorway and left, and two CNAs did not arrive to assist with toileting until about 20 minutes after the call light was activated, despite the resident’s ongoing attempts to get up. Staff later stated that the goal was to answer call lights within 15 minutes, and facility policy required timely response and assistance with bathroom needs and notification of a supervisor if timely response was not possible.
A resident admitted for rehab after brain surgery with a history of subdural hematoma and craniotomy was care planned as at risk for weight loss with a goal to maintain current weight and had a physician order for weekly weights. Facility records showed significant weight loss over several weeks, a missed weekly weight with no documentation of refusal, and no notification to the dietitian despite instructions to report continued weight loss. The dietitian confirmed she was not informed of the ongoing decline and that the resident should have been weighed weekly, while the resident, who was alert and cognitively intact, reported substantial weight loss and decreased appetite following surgery.
Two residents did not receive ordered medications because staff failed to ensure drug availability and timely administration. One resident missed multiple doses of D‑Mannose and Simvastatin when an RN found the medications were not in the pharmacy delivery or stock cart, and documentation showed they were not given due to unavailability. Another resident with Parkinson’s disease did not receive a scheduled bedtime dose of carbidopa‑levodopa, even though it was available in the stock system, and also missed doses of a prescribed statin when it was not obtained from the pharmacy. Staff interviews confirmed that required steps such as using stock medications, requesting STAT delivery, or securing medications from a local pharmacy or family were not consistently followed.
Staff failed to follow infection prevention and control requirements when a resident on contact and droplet precautions for COVID-19 had clearly posted signage and PPE available at the doorway, yet a CNA entered the room with no PPE and an occupational therapist entered without eye protection, contrary to facility policy and the infection preventionist’s expectations. In a separate case, a resident with a PICC line in place after IV antibiotic therapy was not placed on Enhanced Barrier Precautions, with no related orders, signage, or PPE cart outside the room, despite facility policy and the infection preventionist’s statement that residents with indwelling IV access should be on EBP.
Two residents who were eligible for pneumococcal vaccination did not have documentation showing they were offered or received the recommended PCV vaccines according to CDC guidelines. One resident had no pneumococcal vaccine documented despite being over 65 and reporting a prior PPSV23 dose, and another had only a PPSV23 dose recorded with no subsequent PCV dose. The facility’s policy states that recommended vaccines, including PCV20 or PCV15 plus PPSV23, must be offered and administered to eligible residents, and that all immunizations, refusals, and contraindications must be documented, but this was not reflected in these residents’ records.
A nurse administered liquid Ativan, prescribed for one resident, to another resident who did not have a physician's order for this medication form. The act was observed by a CNA, confirmed by video evidence, and not properly documented. This resulted in a medication error, unauthorized administration of a controlled substance, and violation of resident rights and safety standards.
A nurse administered a liquid form of Ativan to a resident without a physician's order, using another resident's medication to manage agitation and anxiety. The medication was not listed on the resident's MAR, and staff interviews confirmed the medication was given without proper authorization, violating facility policy on medication administration.
The facility failed to thoroughly investigate an allegation of narcotic misappropriation involving four residents. An agency LPN, who worked one day, was accused of drug diversion, but the facility did not report the incident to authorities or conduct comprehensive audits and interviews. Discrepancies in narcotic counts were noted, and the LPN exhibited erratic behavior, but the facility did not adhere to its policy for investigating medication discrepancies.
A facility failed to conduct a required narcotic count at shift change, affecting a resident prescribed controlled substances. An RN arrived late and did not perform the count, leading to discrepancies discovered the next morning. An LPN involved exhibited unusual behavior and was escorted out. The facility's policy requires narcotic counts at each shift change, but records showed missing signatures, indicating non-compliance.
A resident with multiple medical conditions, including a history of falls, slid out of bed while reaching for juice, leading to a hospital visit for a suspected bleed. The incident occurred after a CNA left the resident sitting on the bed for over an hour, despite her poor sitting balance. The care plan did not address her sitting balance issues, and staff interviews indicated a lack of active monitoring during the incident.
The facility failed to update infection control policies to include Enhanced Barrier Protection (EBP) and lacked measures to prevent Legionella growth in water systems. Staff were unaware of EBP requirements, leading to inadequate precautions for residents with wounds and catheters. Additionally, there was no water management policy or assessment for Legionella, indicating significant oversight in infection control measures.
The facility failed to maintain resident dignity by serving meals in disposable plastic cups instead of regular dishes to eight residents. The Dietary Manager admitted that the kitchen staff should have transferred the food to small bowls, as using disposable dishes is only appropriate in specific situations like isolation or dish machine malfunctions. This oversight did not align with the facility's policy on resident dignity.
The facility failed to conduct weekly wound assessments for two residents with pressure ulcers, resulting in deficiencies in care. One resident with a stage 2 ulcer did not receive assessments for four weeks, while another with a stage 3 ulcer had incomplete documentation. The DON acknowledged the oversight, citing a lack of a wound program and reliance on hospice and nurse practitioners. The facility's policy requires weekly documentation, which was not consistently followed.
A resident with an indwelling urinary catheter experienced a deficiency in care due to a lack of a catheter secure device and kinked tubing, leading to potential complications. The resident reported not having the secure device for two weeks, and the LPN confirmed the tubing was kinked, necessitating a urine sample. The care plan required a secure device every shift, but documentation showed inconsistencies. The facility's policy did not address secure devices, despite the resident's complex medical history.
LPN Worked While Nursing License Was Suspended
Penalty
Summary
The facility failed to ensure that nursing staff were working with an active nursing license, affecting all 91 residents in the facility. The facility data sheet dated 1/26/26 showed a current census of 91 residents. An undated copy of an LPN’s licensure summary from the state licensing agency showed that this nurse’s license was suspended from 12/15/25 through 12/24/25. Timesheet summaries printed on 1/26/26 showed that this LPN worked on 12/16/25, 12/19/25, and 12/23/25, all during the period of license suspension. Daily census sheets printed on 1/26/26 showed that the facility census was 67 on 12/16/25, 64 on 12/19/25, and 66 on 12/23/25, indicating residents were present while the LPN worked with a suspended license. During an interview on 1/26/26 at 10:20 AM, the Human Resources staff member stated that the LPN did not inform the facility of the temporary suspension and acknowledged that nurses should not work while their licenses are suspended. The state licensing agency’s frequently asked questions indicated that suspended licensees are prohibited from practice during the suspension term and may be subject to certain terms and conditions. No additional resident-specific medical histories or conditions were documented in relation to this deficiency.
Failure to Prevent New Pressure Ulcer in Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with multiple diagnoses including a pathological fracture, congestive heart failure, atrial fibrillation, and osteoporosis, developed a new pressure ulcer on her left heel after admission. Upon admission, the resident was noted to have a surgical wound to her left hip but no other skin issues, and was assessed as cognitively intact but requiring maximum assistance with transfers and bed mobility. The initial skin check performed by an LPN and the nurse manager did not reveal any open areas or redness on the resident's heels. However, approximately one week later, staff alerted the LPN to a pressure ulcer on the resident's left heel, which was found to be unstageable with black tissue present. The facility's care plan for the resident included interventions such as applying ace wraps to both lower extremities, keeping the skin clean and lubricated, monitoring bony prominences for redness, using pillows to avoid direct contact with bony prominences, and utilizing pressure-relieving devices. Despite these interventions, the pressure ulcer developed. The LPN and DON indicated that skin checks were performed weekly, and suggested that the ulcer may have developed between checks. It was also noted that daily full inspections of the feet may not have been performed, especially since the resident's legs were wrapped with ace wraps per physician orders. The facility's policy required systematic assessment, identification of risk factors, and early interventions, but the new pressure ulcer was not identified until it had progressed.
Failure to Supervise High-Risk Resident and Follow Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for residents at risk for accidents, including falls and aspiration. One resident (R1) had diagnoses of Alzheimer’s disease, dementia, anxiety disorder, weakness, and a prior right femoral neck fracture, and her active care plan identified cognitive impairment, extensive ADL assistance needs, use of a mechanical lift for transfers, and high fall risk, with interventions including prompt response to assistance requests and use of bed and chair alarms. On the day of the incident, multiple notes documented that R1 was extremely restless, anxious, and repeatedly attempting to stand from her wheelchair, with staff keeping her at the nurses’ station or taking her room to room to keep her in sight, and that her chair alarm was described as “not very loud.” Despite these known risks and behaviors, R1 was left unsupervised at the nurses’ station when a CNA took another resident to the bathroom and asked another CNA to watch R1; that CNA left the area, and R1 was subsequently found on the floor in the hallway by staff and another resident, bleeding from the back of her head and unable to move her right leg. The RN responding to the incident stated that the nurse assigned to the unit was on lunch break and she did not know where the other unit staff were at the time of the fall. Hospital records following the incident documented that R1 complained of severe right hip and knee pain, with imaging confirming an acute, moderately displaced right femoral fracture requiring surgical intervention. The facility also failed to follow speech therapy and hospital transfer recommendations for another resident (R46) at risk for aspiration. R46, admitted with Parkinson’s disease and dementia, had hospital speech pathology and dysphagia treatment plan documents specifying that he required 1:1 feeding assistance, should not use straws due to aspiration risk, and should continue SLP services and swallowing monitoring. Observations over multiple days showed R46 in his room and at meals with Styrofoam cups containing liquids and straws in them, both on his bedside table and on his meal trays, despite these written precautions. The DON and Director of Therapy acknowledged that staff were expected to follow hospital transfer recommendations and that, until evaluated by the facility speech therapist, the no-straw precaution should have been maintained, and the facility speech therapist later confirmed that his evaluation also recommended no straws for R46’s safety.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors identified a deficiency related to food storage and kitchen sanitation affecting all 35 residents in the facility. During a kitchen tour, an opened box of French baguettes was observed stored directly below the condenser/evaporator in the walk-in freezer, with an unwrapped baguette protruding from the top of the box. The outside of the box had visible ice build-up. The facility’s own Production, Purchasing, Storage Policy required that unused portions and open packages be covered, labeled, and dated, and that bulk materials be stored in NSF-approved containers with tight-fitting lids or in food-grade plastic bags, which was not followed in this instance. In addition to improper food storage, the cooking area was not maintained in a clean and sanitary condition. The exhaust hood above the cooking area had a build-up of dust and debris on the fire suppression lines located directly over the cooking surfaces. The facility’s Sanitation and Infection Prevention/Control Policy stated that written procedures were available for daily and weekly cleaning of all areas and equipment in the department, and that the Maintenance Department was scheduled to clean equipment requiring special training and equipment, such as refrigeration coils and exhaust hoods. Staff interviews confirmed that food in the freezer should be stored securely in sealed bags or containers with lids and that an outside company is responsible for cleaning the exhaust hood, indicating that the observed conditions were inconsistent with facility policies and expected practices.
Failure to Provide Meaningful Activities for Dementia Residents on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, individualized activities to several residents with dementia, despite having a written activities policy and a posted activity calendar. Four residents with dementia were observed over the course of a weekend with no engagement in the scheduled activities. One resident with Alzheimer’s dementia, a former engineer, was observed sitting in a wheelchair in front of the TV, later asleep, and his son reported there were no ongoing activities on Saturdays or Sundays and that he wanted his father to be engaged. This resident’s activity care plan documented impaired cognitive function/dementia but contained no activity interventions. Another resident with dementia, anxiety, and mood disorders was observed wheeling herself around the activity and dining rooms, being repeatedly redirected by an LPN, and later sitting in a wheelchair facing the TV stating there was nothing to do; her activity care plan also documented impaired cognitive function/dementia but had no activity interventions. A third resident with Alzheimer’s dementia was observed asleep in a wheelchair in front of the TV and later awake and looking around with no ongoing activities, despite a care plan stating the resident was dependent on staff for leisure pursuits and that Life Enrichment would provide individual visits and monitor participation. A fourth resident with dementia was observed sitting in a recliner and later at an activity table just looking around, again with no activities occurring, and had no activity care plan in the record. The Memory Care Activity Calendar listed multiple structured activities throughout the day, including positive affirmation, 1:1 reminisce, short stories, games, music and movement, and sensory exploration, but none of these were provided. Nursing staff, including an LPN and several CNAs, reported there were no activities on weekends in the dementia unit, that they tried to talk with residents or sit them by the TV in between nursing tasks, and that they had their own duties such as toileting, transferring, and feeding. The Life Enrichment Director and the Director of Memory Wellness both acknowledged that residents in the dementia unit need activities for engagement and that there was no activity staff on weekends, even though the facility’s activities policy states that meaningful, ability-centered activities for residents with cognitive or memory diseases are to be continually available.
PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication order included a required stop date for one resident receiving an antianxiety medication. Record review showed that the resident’s physician order sheet, dated 11/5/25, contained an order for Ativan 0.25 ml sublingual every 2 hours as needed for anxiety, with no stop date indicated. During interview, the Nurse Manager stated he was responsible for ensuring psychotropic medications had appropriate diagnoses and stop dates and acknowledged he was not aware that this antianxiety order lacked a stop date, noting that the order was carried out by hospice staff and should have been clarified. He further stated he did not know why the order was entered into the electronic chart without a stop date and later produced a separate document for the antianxiety order that was not reflected in the resident’s medical record, despite his assertion that all ordered medications, including psychotropics with stop dates, should appear there. The facility’s psychotropic medication policy, dated 8/25, documents that psychotropic medications are to be used, evaluated, and monitored in accordance with state and federal guidelines.
Failure to Provide Timely Toileting Assistance for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting assistance to a resident who was dependent on staff for ADLs. The resident had Parkinson’s disease, dementia, and an ADL self-care deficit due to weakness, requiring staff assistance. On the observed date and time, the resident was found confused, very restless, with his legs partially off the bed, repeatedly stating he needed to stand up and use the bathroom. The surveyor immediately activated the call light and remained with the resident, encouraging him to stay in bed and wait for help. A CNA who was not assigned to the unit entered the room 12 minutes after the call light was activated, turned off the call light, and left to find the assigned CNA. Four minutes later, an RN appeared at the doorway, stated that CNAs were coming, and then left, while the resident continued attempting to get up to use the bathroom. Two CNAs finally entered the room 20 and 22 minutes after the call light was activated to assist the resident to the bathroom, with one CNA stating the resident required two staff for transfers. After toileting, a CNA stated that the goal was to answer call lights within 15 minutes, but that it depended on unit acuity and what was going on. The facility’s Call Light System policy required staff to respond and assist a resident to the bathroom in a timely manner and to notify a supervisor if unable to respond timely due to workload or an emergency.
Failure to Monitor and Report Ongoing Weight Loss and Obtain Ordered Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and respond to a resident’s weight loss and to follow its own policy for obtaining weekly weights after admission. The resident had been hospitalized for a subdural hematoma and underwent a craniotomy before being admitted to the facility for rehabilitation. The admission care plan identified the resident as being at risk for weight loss with a goal to maintain current weight. A physician’s order directed that the resident be weighed weekly, every Tuesday, and the facility’s policy required weekly weights for the first four weeks after admission. The weight records showed documented weights of 179 lbs on admission, 170.4 lbs one week later, and 167.4 lbs two weeks after that, but no weight was documented on the intervening Tuesday, and there was no documentation that the resident refused to be weighed. The records showed a 6.5% weight loss from admission to the later date. The dietitian assessed the resident shortly after admission and again after the initial significant weight loss, attributing the early loss to fluid shifts and resolving edema from hospitalization and IV fluids, and directed staff to continue monitoring weights and to notify her of any continued weight loss. Despite further documented weight loss between the second and third recorded weights, there was no evidence that staff notified the dietitian of this continued decline. During interview and record review, the dietitian confirmed that the resident should have been weighed weekly, that she had not been informed of the ongoing weight loss, and that she would have reassessed the resident if notified. The resident, who was alert and cognitively intact, reported having lost a lot of weight since surgery, described a decreased appetite after surgery that had only recently begun to improve, and stated he had been weighed a couple of times in the facility and had not refused to be weighed.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for two residents. One resident was admitted with physician orders for D‑Mannose 500 mg, four capsules by mouth three times daily, and Simvastatin 40 mg once daily. Over several days following admission, the resident received no doses of D‑Mannose and missed doses of Simvastatin on two days. During a morning medication pass, an RN stated that the D‑Mannose was not available because it had not been received from the pharmacy and was not in the stock medication cart, and also confirmed that Simvastatin had not been available on prior days. The MAR and progress notes documented that these medications were not given because they were unavailable or awaiting pharmacy delivery, despite facility policy requiring use of stock medications and STAT pharmacy delivery when medications are not on hand. Another resident was admitted with hospital discharge orders for carbidopa‑levodopa to be given multiple times daily for Parkinson’s disease and Pravastatin for cholesterol control. The MAR showed that the resident did not receive an evening dose of carbidopa‑levodopa on the day of admission and did not receive Pravastatin on the first two days. The DON reported that the nurse on duty confirmed the resident’s wife brought in and gave one dose of carbidopa‑levodopa, but the nurse did not administer the bedtime dose, even though carbidopa‑levodopa was available in the facility’s stock medication cart. The DON also stated that Pravastatin should have been obtained from the pharmacy and administered but was not. A nurse later confirmed with the pharmacy that carbidopa‑levodopa was available in the stock system while Pravastatin was not, and explained that if medications were not available in the stat safe or stock, they should contact the NP for a stat order and obtain the medication from a local pharmacy or through the family.
Failure to Use Required PPE for COVID-19 Isolation and Enhanced Barrier Precautions for PICC Line
Penalty
Summary
The deficiency involves failures in implementing required infection prevention and control measures for residents on transmission-based precautions and those requiring Enhanced Barrier Precautions (EBP). One resident with a documented COVID-19 infection was ordered to be on contact and droplet precautions, with signage posted outside the room specifying the need for gowns, gloves, face shields or goggles, and masks, and a bin of PPE available at the doorway. Despite this, a CNA was observed entering the resident’s room without any PPE to turn off the call light, and an occupational therapist later entered the same room without donning a face shield. The infection control nurse confirmed that no staff should enter the COVID-19 isolation room without all required PPE and that eyeglasses alone are not acceptable in place of a face shield. A second deficiency involved a resident admitted with sepsis and bacteremia who had a PICC line in the left arm for IV antibiotic administration. Although IV antibiotics were completed, the PICC line remained in place, and there was no physician order or documentation placing the resident on EBP related to the indwelling device. The facility’s isolation list did not show the resident on EBP or any isolation precautions, and repeated observations showed the resident in bed with the PICC line in place, but without any EBP signage on or around the door and without an isolation cart or PPE available near the room. The infection preventionist stated that residents with a PICC line or any type of IV access should be on EBP, and the facility’s EBP policy required signage and readily available gowns and gloves for residents with indwelling medical devices.
Failure to Offer Recommended Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The deficiency involves the facility’s failure to ensure that eligible residents were offered pneumococcal vaccination in accordance with CDC recommendations and the facility’s own immunization policy. For one resident (R23), the face sheet showed admission to the facility and age over 65, and the Immunizations Report showed no pneumococcal vaccine on record. A progress note documented that this resident reported having received a Pneumococcal 23 (PPSV23) vaccination after age 65, but no additional documentation of any pneumococcal vaccine was available in the record. For another resident (R36), the face sheet showed admission and age over 65, and the Immunizations Report documented a PPSV23 vaccine administered on 12/8/21, with no other pneumococcal vaccines recorded and no further documentation provided. During an interview, the Administrator in training stated that the unit clerk is responsible for tracking residents’ immunization status and determining when they are due for specific immunizations, and that the facility follows CDC recommendations for pneumococcal and other vaccines. The CDC Adult Immunization Schedule cited in the report specifies that adults aged 65 years or older who have previously received only PPSV23 should receive one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose. The facility’s written Immunization Policy and Procedure, revised in 9/2025, states that the facility shall offer and administer recommended vaccines to all eligible residents, document all immunizations, refusals, and contraindications, comply with CDC requirements, and provide PCV20 or sequential PCV15 plus PPSV23 per CDC guidelines upon admission and as needed based on immunization history. Despite these policies and guidelines, the records for R23 and R36 did not show that the appropriate pneumococcal vaccines were offered or administered in line with CDC recommendations.
Unauthorized Administration of Controlled Substance and Misappropriation of Medication
Penalty
Summary
A nurse administered a liquid medication, specifically Ativan (Lorazepam Oral Concentrate), to a resident who did not have a physician's order for this form of the medication. The resident's medication administration record (eMAR) showed only an order for Ativan tablets, not the liquid form, at the time of administration. The incident was observed by a CNA, who reported that the nurse stated she was giving an 'extra dose' and asked the CNA not to witness the act. Video evidence confirmed the nurse gave the resident a liquid medication with a distinctive white stopper, which matched another resident's prescribed Ativan. The nurse did not document the administration of this medication to the resident and instead recorded a dose for the resident who was actually prescribed the liquid Ativan. The facility's investigation determined that the nurse gave a controlled substance to a resident without a valid order and used medication prescribed for another resident. This was classified as a medication error, unauthorized administration of a controlled substance, and a violation of resident rights and safety standards. Staff interviews confirmed that such actions are outside the scope of nursing practice and violate facility policy, which prohibits the use of a resident's possessions, including medications, without proper authorization.
Unauthorized Administration of Ativan Without Physician Order
Penalty
Summary
A medication error occurred when a nurse administered a liquid form of Ativan to a resident who did not have a physician's order for this medication or formulation. The resident, who had a history of atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness, agitation, and mood disorder, was observed to be anxious and agitated. The nurse gave the resident a liquid medication from a dropper, which was later confirmed through video review to be Ativan belonging to another resident. The medication administration record for the resident did not include any oral liquid medications, and there was no valid order for liquid Ativan at the time of administration. Staff interviews confirmed that the nurse gave the medication without a physician's order and used another resident's medication. The incident was reported by a CNA who witnessed the event and was corroborated by other staff, including the DON and RNs, who emphasized that medications should not be borrowed or administered without proper orders. The facility's policy requires strict adherence to the five rights of medication administration, including verifying the right resident, medication, dose, route, and time, and administering medications only from packaging labeled for the individual resident. This policy was not followed in this incident.
Failure to Investigate Alleged Misappropriation of Narcotics
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of narcotic medications involving four residents in certified beds. The incident occurred when an agency LPN, who worked only one day at the facility, was accused of drug diversion. The Director of Nursing (DON) and the Administrator did not report the allegation to the state agency or the police, citing a lack of proof and fear of legal repercussions. The facility did not perform audits on units other than the sheltered care unit, where the LPN was assigned, and failed to interview all staff involved, including the maintenance man who escorted the LPN out of the facility. The incident began when discrepancies in the narcotic count were noticed by a Registered Nurse (RN) who worked the night shift on Christmas Eve. The RN did not count the narcotics upon arrival, assuming it was done by someone else. The next morning, the count was off, and the RN attempted to involve the agency LPN, who was acting erratically and did not cooperate. Another RN noticed discrepancies in the narcotic cards and called the LPN to verify the count. The LPN was described as rushed and exhibiting unusual behavior, such as trying to access the medication refrigerator under the pretense of getting lunch. The facility's policy requires that all discrepancies, suspected loss, or diversion of medications be reported to the Administrator, DON, and Consultant Pharmacist, and an investigation be conducted. However, the facility did not adhere to this policy, as evidenced by the lack of comprehensive interviews and audits. Additionally, the facility's pharmacy consultant confirmed there was no test available to verify if morphine or lorazepam liquids were tampered with, and the facility did not provide records of medication cart and drug audits. The failure to follow established protocols and conduct a thorough investigation into the alleged misappropriation of narcotic medications resulted in a deficiency finding.
Failure to Conduct Narcotic Count at Shift Change
Penalty
Summary
The facility failed to ensure a narcotic count was completed upon nursing shift change, specifically affecting a resident who was prescribed controlled substances, including lorazepam and morphine. The incident involved a registered nurse (RN) who arrived late for her shift on Christmas Eve and did not perform the required narcotic count, assuming it had been done by someone else. The following morning, discrepancies in the narcotic count were discovered by another RN, who attempted to address the issue with an agency licensed practical nurse (LPN) who had been on duty. The LPN was reportedly rushed and exhibited unusual behavior, such as attempting to access the medication refrigerator for personal reasons, which led to her being escorted out of the facility. The Director of Nursing (DON) confirmed that narcotic counts should be conducted at every shift change, and the facility's policy mandates that all Schedule II-V controlled medications be counted by two nurses at each shift change. The Controlled Substance Shift to Shift Count Record for December 2024 showed missing signatures for the morning and evening shifts on December 25, 2024, indicating that the required counts were not completed. This failure to adhere to established procedures for narcotic counts resulted in a deficiency in the facility's pharmaceutical services.
Resident Fall Due to Inadequate Supervision and Positioning
Penalty
Summary
The facility failed to ensure a resident was positioned safely in bed, leading to a fall incident. The resident, who was on blood thinner medication, attempted to reach for cranberry juice and slid out of bed, resulting in a hospital visit for a suspected subarachnoid bleed. The incident occurred when a CNA from an agency left the resident sitting on the side of the bed for over an hour, despite the resident's poor sitting balance and tendency to lean forward and fall asleep. The resident's care plan did not adequately address her sitting balance issues or the need for supervision while sitting. The resident, identified as having multiple medical conditions including atrial fibrillation, type 2 diabetes, and a history of falling, was found on the floor by staff. The CNA had placed a tray table in front of the resident, which she pushed away after eating, leading to her sliding off the bed. The resident's care plan indicated she required assistance with mobility and transfers, but it did not specify her poor sitting balance or the need for additional supervision when sitting up. Staff interviews revealed that the CNA was not actively monitoring the resident, and the nurse on duty was at the end of the hall during the incident. The facility's fall prevention policy required staff training on fall prevention, but the incident suggests a lapse in adherence to these protocols. The Director of Nursing acknowledged that the resident should not have been sitting on the side of the bed, as she was unable to do so safely on her own.
Infection Control Deficiencies in EBP and Water Management
Penalty
Summary
The facility failed to ensure their infection control policies and procedures were reviewed annually and updated to include Enhanced Barrier Protection (EBP). The Infection Preventionist (V3) was unaware of the requirements for EBP and stated that there was no need for postings or signs on residents' doors to indicate the enhanced barrier precautions. This lack of awareness extended to other staff members, such as a Licensed Practical Nurse (V6), who noted that residents with catheters and open wounds should be on EBP but acknowledged that this was not in place at the facility. The facility's policies, including those for Covid-19, antimicrobial stewardship, and flu and pneumovax, were outdated and did not include EBP procedures. The facility also failed to have measures in place to prevent the growth of Legionella in the water systems. The Maintenance Supervisor (V4) admitted that there had been no assessment of the water systems, no diagram of the water systems, and no monitoring protocols or policies for Legionella. The Administrator (V1) confirmed the absence of a water management policy and assessment for Legionella, indicating a significant oversight in the facility's infection control measures. Specific residents, such as R10 and R17, were not placed on EBP despite having conditions that warranted such precautions. R10 had multiple wounds and required daily dressing changes, yet staff did not wear gowns or follow EBP protocols. Similarly, R17, who had a pressure ulcer and other medical conditions, did not have any EBP signs or PPE available at the doorway, and staff only used gloves during care. The lack of EBP policies and procedures contributed to these deficiencies, as staff were not informed or trained on the necessary precautions for residents with specific medical needs.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat eight residents with dignity during a meal service. On the specified date, these residents were served their noon meal with water, fruit cups, pasta salad, and cucumber tomato salads in disposable plastic cups instead of regular dishes. The Dietary Manager acknowledged that the kitchen staff should have transferred the food from the plastic cups to small bowls available in the facility, as using disposable dishes is only appropriate when a resident is on isolation or if there is a malfunction with the dish machine. This oversight was identified as a dignity concern, as it did not align with the facility's policy that emphasizes maintaining resident dignity by using normal dishes.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to complete weekly wound assessments for two residents with pressure ulcers, leading to deficiencies in their care. Resident R17, who has a stage 2 pressure ulcer, did not receive weekly wound assessments for a period of four weeks. The Director of Nursing (DON) acknowledged the oversight, mistakenly believing that hospice was responsible for the assessments. The facility's policy requires weekly documentation of wound status, including size, color, drainage, and odor, which was not adhered to in this case. Resident R10, admitted with a stage 3 pressure ulcer, also did not receive complete weekly skin assessments for his pressure injuries. Observations revealed that R10 had multiple wounds, including on his buttock and coccyx, but the documentation was incomplete and not up to date. The DON admitted that there was no wound nurse in the building and that the nurse practitioner only reviewed wounds upon request. The nurse manager stated that the facility lacked a wound program, and the nurses were responsible for measuring and documenting wounds weekly. The facility's failure to conduct and document weekly wound assessments for both residents R17 and R10 highlights a significant gap in their wound care management. The lack of a dedicated wound program and reliance on hospice and nurse practitioners without proper oversight contributed to the deficiencies. The facility's policy mandates weekly wound assessments, which were not consistently performed, leading to inadequate monitoring and documentation of the residents' pressure ulcers.
Failure to Ensure Proper Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to a deficiency. The resident, who had an indwelling urinary catheter, was observed with a kinked catheter tubing and without a catheter secure device in place. The resident reported that the secure device had not been used for two weeks, suggesting a possible shortage of these devices. The resident also mentioned that the catheter was leaking at the time of observation. The Licensed Practical Nurse (LPN) acknowledged that the tubing was kinked and stated that this was the reason for collecting a urine sample. The LPN also noted that the tubing often became kinked when the resident moved or sat, indicating a need for closer monitoring. The resident's care plan and physician orders required the use of a catheter secure device every shift to prevent tension on the urinary meatus and potential infection. However, documentation showed inconsistencies in the application of the secure device, with records indicating it was in place only on specific dates. The facility's catheter care policy emphasized maintaining unobstructed urine flow but did not address the use of catheter secure devices. The resident had multiple diagnoses, including Parkinson's disease and mechanical complications of the urinary catheter, which could contribute to the complexity of care required.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 200 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Bluff Nursing Home | 0.9 mi | ★★★★★ | 6 | 0 |
| Rock River Health Care | 1.2 mi | ★★★★★ | 14 | 1 |
| East Bank Center, Llc | 1.3 mi | ★★★★★ | 1 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 1.5 mi | ★★★★★ | 0 | 0 |
| Amberwood Care Centre | 1.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.