Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Of Richmond during CMS and state inspections, most recent first.
A resident with cognitive intactness and hemiplegia reported a lost cell phone to staff, but no grievance form was completed or forwarded to the grievance official as required by policy. The resident received no follow-up and had to use the nurse's station phone, despite her care plan noting the importance of phone communication. Staff interviews confirmed the grievance process was not followed.
Surveyors identified unsanitary conditions in the kitchen, including a black substance along the dish sink area and significant ice buildup throughout the walk-in freezer. The Dietary Manager was aware of these issues but had not yet addressed them, and the Director of Maintenance was unaware until notified during the survey. These deficiencies affected the environment where food was prepared and stored for nearly all residents.
A resident with dementia and protein-calorie malnutrition, who required assistance with ADLs and was unable to obtain fluids independently, was repeatedly observed without water or fluids at the bedside. Despite care plan interventions and facility policy requiring fluid availability and encouragement, staff did not ensure fluids were accessible, as confirmed by the DON.
A resident with dementia and protein-calorie malnutrition, who was assessed as needing assistance with eating, was repeatedly left alone during meals without staff support. Observations showed the resident either sleeping with a full tray, confused about how to use utensils, or struggling to feed herself, despite care plans and assessments indicating the need for one-person assistance.
A resident with a documented acetaminophen allergy was administered the medication multiple times after admission, despite clear hospital discharge records and verbal reports from the resident and her family. The allergy was not added to the care plan until months later, and staff interviews confirmed that the allergy was not recognized or addressed as required by facility policy.
A resident with CHF and COPD was found to have an oxygen concentrator at the bedside and reported using oxygen at night, but there was no physician order for oxygen therapy. The DON confirmed the oxygen may have been started during a CHF episode and was not discontinued, contrary to facility policy requiring a physician's order for oxygen administration.
A resident did not receive their prescribed Xanax medication upon returning from the hospital due to a transcription error. The facility failed to resume the medication as ordered, despite hospital discharge instructions. The resident, with a history of seizures and Xanax usage, experienced a possible seizure and change in mental status, leading to another hospitalization. The facility's policy for verifying medication orders was not properly followed.
The facility failed to accurately document meal intakes and oral hygiene for three residents. Meal records showed multiple instances of undocumented or incorrectly marked meals, while oral care documentation was inconsistent. Interviews revealed confusion in the EHR system, contributing to these deficiencies.
The facility failed to accurately encode various aspects of the MDS for five residents, leading to discrepancies in their medical records. Errors included incorrect smoking status, GDR contraindication dates, life expectancy, discharge planning, and use of a BiPap machine. The MDS Coordinator acknowledged these errors and indicated plans to modify the assessments accordingly.
The facility failed to timely complete and transmit an entry tracking record for a resident admitted with cerebrovascular disease. The MDS Coordinator confirmed the record was not completed and would be late, contrary to the facility's policy requiring submission within 7 days.
The facility failed to develop and implement care plans for three residents with specific medical needs, including the use of a bipap machine, insulin for diabetes, anticonvulsant medication for seizures, and pain management. The deficiencies were confirmed by the MDS Coordinator and the Administrator.
The facility failed to assess and document bruising on a resident's forearms, despite the resident being on medication that increases bruising risk and having no prior skin issues. The bruising was observed on 4/15/24, but no documentation or assessment was made until 4/18/24, contrary to the facility's Skin Management policy.
A facility failed to implement a physician's order for a resident's left hand contracture. The resident, with multiple diagnoses including dementia and heart failure, was observed multiple times without the prescribed splint/carrot. The care plan required the carrot to be worn for 4-6 hours daily, but it was not consistently applied, and staff were unable to locate it in the resident's room.
Failure to Forward and Address Resident Grievance Regarding Lost Personal Item
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's grievance regarding a lost cell phone was properly forwarded to the grievance official and addressed according to policy. The resident, who was cognitively intact and had diagnoses including hypertension and flaccid hemiplegia, reported to nursing staff that her cell phone had been missing for a couple of months. Despite informing staff, the resident did not receive any follow-up regarding the lost item and had to use the nurse's station phone to make or receive calls. The resident's care plan indicated that she enjoyed talking with her family on the phone, highlighting the importance of the missing item to her daily life. Interviews with staff revealed that a CNA was aware of the missing phone and verbally informed the Social Service Director (SSD), but no grievance form was completed or forwarded as required by facility policy. The SSD could not recall being told about the missing phone and confirmed that no grievance form was filled out. The facility's grievance policy specified that staff receiving a grievance must document it on a designated form and forward it to the grievance official, who is responsible for tracking and resolving grievances. This process was not followed in the case of the resident's lost cell phone.
Sanitation Deficiencies in Kitchen and Walk-In Freezer
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, as evidenced by the presence of a black substance along the dish sink area beside the dishwasher and underneath the soap dispenser. This substance had been present for approximately two weeks, and the Dietary Manager was aware of it but had not yet arranged for cleaning or re-caulking, instead waiting for maintenance to address the issue. The Director of Maintenance was unaware of the problem until it was pointed out and acknowledged that the area needed to be bleached and re-caulked. Additionally, the walk-in freezer was observed to have significant ice buildup on the ceiling, walls, fans, floor, bags of food, and door handle. The Dietary Manager explained that a recently repaired fan had previously allowed water condensation to accumulate, which then froze after the repair. The ice on the floor created a slick surface, and the Dietary Manager expressed concern about safely entering the freezer. The Director of Maintenance was also unaware of the ice buildup and stated that a plan was needed to remove all items from the freezer to allow it to thaw. The facility's sanitation inspection policy required daily and weekly inspections of food service areas, including the freezer and pot wash areas.
Failure to Ensure Bedside Fluid Availability for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure the availability of fluids at the bedside for a resident with diagnoses including dementia and protein-calorie malnutrition. Multiple observations over several days revealed that the resident, who was severely cognitively impaired and required assistance with activities of daily living, did not have water or fluids accessible at the bedside. On several occasions, the resident was observed lying in bed without any fluids available, and at one point, only an empty cup was present. The resident's care plan specifically indicated the need for staff to encourage fluid consumption and ensure fluid availability at the bedside due to the resident's risk for altered nutrition and inability to initiate fluid intake independently. The facility's hydration policy also required that beverages be available and within reach of residents. During an interview, the DON confirmed that staff were expected to offer fluids to the resident whenever entering the room, acknowledging that the resident could not obtain fluids on her own.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary assistance with eating for a resident who was unable to perform this activity independently. The resident, who had diagnoses including dementia and protein-calorie malnutrition, was observed on multiple occasions lying in bed with a full lunch tray in front of her, either sleeping or appearing confused and unable to use eating utensils properly. No staff were present to assist her during these times. On another occasion, the resident was seen attempting to feed herself but had difficulty getting food onto her utensils, missed her mouth, and dropped food onto herself. Clinical documentation indicated that the resident was severely cognitively impaired and required partial to moderate assistance with eating, as well as cueing at meals. The care plan specified that she needed one-person assistance with eating and should be up out of bed for all meals. Despite these documented needs, staff failed to provide the required assistance, leaving the resident without support during mealtimes.
Failure to Address Documented Medication Allergy
Penalty
Summary
A resident with a diagnosis including congestive heart failure was admitted to the facility with a documented allergy to acetaminophen (Tylenol), as noted in her hospital discharge records. Despite this, the facility's physician orders included acetaminophen for general discomfort, and the medication was administered to the resident on multiple occasions over a two-month period. The allergy was not added to the resident's care plan until several months after her admission, even though both the resident and her daughter had informed staff of the allergy, and the hospital discharge documentation clearly indicated it. Interviews with the Director of Nursing (DON) revealed that staff failed to recognize and address the documented acetaminophen allergy upon the resident's return from the hospital. The DON acknowledged that the allergy should have been documented and addressed earlier, especially after the resident reported her inability to take acetaminophen during a care plan meeting. The facility's Medication Administration policy required verification of allergies before administering medications, but this protocol was not followed in this case.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
A resident with diagnoses including congestive heart failure and chronic obstructive pulmonary disease (COPD) was observed with an oxygen concentrator at the bedside and reported using oxygen at bedtime. Multiple observations confirmed the ongoing presence of the oxygen equipment in the resident's room. Review of the clinical record and order summary revealed that there was no physician's order for oxygen therapy for this resident at the time of the observations. The resident's care plan identified a risk for shortness of breath and included an intervention to administer oxygen per physician's order. However, the DON confirmed that the oxygen may have been initiated as a nursing measure during a CHF flare-up and was not discontinued or removed when no longer needed. Facility policy required that oxygen be administered only under a physician's order, which was not followed in this case.
Medication Error: Failure to Administer Xanax as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, Xanax, as ordered by the physician. The resident was admitted with a 7-day order for Xanax 2 mg twice daily, which was not properly resumed upon their return from the hospital. Despite hospital discharge instructions indicating the continuation of Xanax, the medication was not restarted due to a prior stop date. The medication administration record (MAR) did not reflect the administration of Xanax after the resident's return, and the facility was unaware of the error until a staff member followed up with the hospital. The resident, who had a long history of seizure activity and Xanax usage, experienced a possible seizure and change in mental status, leading to another hospitalization. The neurologist noted that the abrupt withdrawal from Xanax likely contributed to the seizures. The facility's policy required verification of medication orders upon a resident's return from the hospital, but this was not properly executed, resulting in the medication error. The facility's administrator acknowledged the oversight and the failure to resume the Xanax order as prescribed.
Inaccurate Documentation of Meal Intakes and Oral Hygiene
Penalty
Summary
The facility failed to maintain accurate documentation of meal intakes and oral hygiene for three residents, identified as Residents B, C, and D. For Resident B, the electronic health record (EHR) showed multiple instances of undocumented meal intakes, with several meals marked as 'not available' instead of 'resident refused' when meals were declined. Additionally, oral care was inconsistently documented, with some days showing incomplete or missing records. Interviews with the Regional Nurse Consultant and the MDS Coordinator revealed confusion regarding the documentation process and the representation of meal intake data in the EHR. Resident C's records also exhibited similar issues, with several meals marked as 'not available' and some meals left undocumented. Oral care documentation for Resident C showed inconsistencies, with some days having fewer than the required three instances of oral care. The MDS Coordinator's interview highlighted a lack of clarity in the EHR's meal intake graph, which did not clearly identify meal times, leading to potential inaccuracies in documentation. For Resident D, the documentation of meal intakes was unclear, with entries made at inconsistent times and some meals not documented at all. The EHR did not specify which meal was being recorded, leading to further confusion. Oral care documentation for Resident D was also inconsistent, with some days showing incomplete records or no documentation at all. The facility's policies on meal serving and oral care were not effectively implemented, as evidenced by the discrepancies in the EHR documentation.
Inaccurate MDS Encoding for Multiple Residents
Penalty
Summary
The facility failed to accurately encode various aspects of the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. Resident 30, diagnosed with chronic obstructive pulmonary disease, was inaccurately recorded as a non-smoker despite a smoking care plan indicating otherwise. Resident 41, with vascular dementia and schizoaffective disorder, had an incorrect date for the contraindication of a gradual dose reduction (GDR) for antipsychotic medication. The correct date was 12/27/2023, but the MDS recorded it as 6/30/2023. Resident 50, who had a stroke and was utilizing hospice services, was not recorded as having a life expectancy of less than six months, contrary to the hospice certification. Resident 51, with a displaced comminuted fracture of the patella, was incorrectly documented as having an unplanned discharge, despite care plans and progress notes indicating a planned discharge. Resident 103, with multiple diagnoses including obstructive sleep apnea, was not recorded as using a BiPap machine, although physician orders and observations confirmed its use. The MDS Coordinator acknowledged these errors and indicated plans to modify the assessments accordingly. These inaccuracies in the MDS assessments were identified through interviews and record reviews conducted by surveyors. The MDS Coordinator admitted to the errors and stated that modifications would be made to correct the records. The facility's policy for MDS 3.0 Completion emphasizes the importance of accurate and comprehensive assessments to identify care needs and develop appropriate care plans. However, the deficiencies in encoding critical information for these residents highlight lapses in adhering to this policy, affecting the accuracy of the residents' medical records and potentially their care plans.
Failure to Timely Complete Entry Tracking Record
Penalty
Summary
The facility failed to timely complete and transmit an entry tracking record for one resident, identified as Resident 154, who was admitted with a medical diagnosis of cerebrovascular disease. Upon review of the clinical record on 4/17/2024, it was found that no MDS assessment or entry tracking record had been completed for this resident. An interview with the MDS Coordinator confirmed that the entry tracking record was not completed and would be late, with the latest anticipated date of completion being 4/9/2024. The facility's policy requires entry tracking to be completed and submitted within 7 calendar days of entry into the facility.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents with specific medical needs. Resident 103, who had diagnoses including acute on chronic congestive heart failure, heart disease, high blood pressure, type 2 diabetes mellitus with diabetic nephropathy and diabetic retinopathy with macular edema, and obstructive sleep apnea, did not have care plans for the use of a bipap machine or insulin for diabetes mellitus. Despite physician's orders for the use of a bipap machine and specific insulin dosages, these were not reflected in the resident's care plan. The MDS Coordinator acknowledged the absence of these care plans and indicated they would be added later. Resident 41, diagnosed with vascular dementia and schizoaffective disorder, had a physician's order for the anticonvulsant medication Keppra to manage seizures. However, there was no care plan in place for the seizure disorder or the use of Keppra. The Administrator confirmed the lack of a care plan for this resident's seizure management. Additionally, Resident 5, who had chronic pancreatitis, coronary heart disease, arthritis, chronic kidney disease, and dementia, frequently experienced pain and required repositioning for relief. Despite these observations and a progress note indicating severe back pain, there was no care plan addressing the resident's pain management. The MDS Coordinator confirmed the absence of a pain management care plan for Resident 5 and indicated that one was implemented later.
Failure to Assess and Document Bruising
Penalty
Summary
The facility failed to assess and document bruising on Resident 29, who was observed to have dark purple bruises on both forearms on 4/15/24. The resident, who has diagnoses including heart disease, lung disease, transient ischemic attacks, and long-term atrial fibrillation, indicated she did not know how the bruising had occurred. A review of Resident 29's record on 4/18/24 showed no documentation of the bruising or any assessment of how it occurred, despite the resident being cognitively intact and having no prior skin issues as per the Quarterly Minimum Data Set (MDS) assessment dated 3/22/24. The current physician's orders included Clopidogrel Bisulfate, a medication that can increase bruising risk, but there was no documentation addressing the bruising in the progress notes or nursing assessment dated [DATE]. On 4/19/24, the Administrator provided a follow-up investigation document dated 4/18/24, which included measurements and descriptions of the bruises but no known cause for the injury. The facility's Skin Management policy requires skin assessments upon admission and no less than weekly, with any new bruises to be documented in the medical record. However, the policy was not followed as the bruising was not documented or assessed in a timely manner. The Administrator indicated that the bruising was first noticed on 4/18/24, contradicting the observation made on 4/15/24.
Failure to Implement Physician's Order for Hand Contracture
Penalty
Summary
The facility failed to implement a physician's order for a resident's left hand contracture. The resident, who had diagnoses including dementia, major depression, heart failure, and hypertension, was observed multiple times without the prescribed splint/carrot in place. Observations on four different days revealed that the resident did not have the splint/carrot in place while sitting in a wheelchair or lying in bed. During an interview, a Qualified Medication Aide (QMA) was unable to locate the carrot in the resident's room and later found it at the nursing station. The Assistant Director of Nursing (ADON) indicated that Certified Nursing Assistants (CNAs) were responsible for ensuring the carrot was in place. The resident's care plan, dated November 2019, specified that the resident should wear the left hand carrot for 4-6 hours a day. Additionally, the care plan dated February 2024 indicated the resident was at risk for skin breakdown and moisture-associated skin disorder due to the contracture. The Quarterly Minimum Data Set (MDS) assessment from February 2024 noted the resident was severely cognitively impaired and had limited range of motion in both upper extremities. The April 2024 physician recapitulation reiterated the need for the resident to wear the carrot for four hours a day or as tolerated. The facility's Range of Motion (ROM) policy required nurses to monitor the consistent implementation of care plan interventions, but this was not adhered to in this case.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosebud Village | 0 mi | ★★★★★ | 0 | 0 |
| Springs Of Richmond, The | 0.5 mi | ★★★★★ | 14 | 0 |
| Brickyard Healthcare - Richmond Care Center | 2.7 mi | ★★★★★ | 14 | 0 |
| Forest Park Health Campus | 3.4 mi | ★★★★★ | 12 | 0 |
| Arbor Trace Health & Living Community | 3.8 mi | ★★★★★ | 1 | 0 |
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