Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Point Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure the director of food and nutrition services was a certified dietary manager (CDM), placing residents at risk for unmet dietary and nutritional needs. Dietary BB had not yet taken the certification test, and the registered dietician was only available by phone and visited twice a month. The facility lacked a policy regarding the CDM.
A facility with 29 residents was found to have deficiencies in food storage practices. Observations revealed unlabeled and undated food items, including a pitcher of juice, Kool-Aid, and several glasses of juice and milk without covers. The dishwashing area had unwashed dishes from the previous night and a musty odor. Dietary staff acknowledged the oversight, noting that all food items should be labeled and dated, and the facility lacked a policy on food storage.
The facility failed to conduct required criminal background checks for a Licensed Nurse and a Housekeeping staff member upon hire, as per its policy. This oversight allowed the employees access to residents without verifying their history of abuse, neglect, exploitation, or mistreatment, placing residents at risk.
The facility failed to secure hazardous cleaning chemicals, leaving them accessible to seven cognitively impaired, independently mobile residents. An inspection revealed that the restorative room was left unlocked with multi-purpose cleaners stored in an unlocked cabinet. A CNA and an Administrative Nurse acknowledged that these chemicals should be secured to prevent resident access, as per the facility's policy.
The facility failed to conduct proper safety assessments and obtain informed consent for the use of bed rails for several residents, including those with cognitive impairments and mobility issues. This oversight led to potential safety risks, as the facility did not document the risks associated with low air-loss mattresses or communicate these risks to residents or their representatives.
A resident with severe cognitive impairment and physical limitations was pushed in a wheelchair without foot pedals on multiple occasions, leaving her vulnerable to accidents. Staff acknowledged the necessity of foot pedals, but the facility lacked a policy to ensure their use, resulting in unmet care needs.
A resident with severe cognitive impairment and a primary language other than English did not receive adequate support for communication and socialization. Despite having a care plan that included an interpreter and media in his native language, these were not consistently used. The resident was often left without communication aids, and staff did not engage with him during meals or in common areas, increasing his risk of isolation.
A resident with severe cognitive impairment and a history of Stage 3 pressure ulcers had their low air-loss mattress set incorrectly, contrary to physician's orders. The mattress was observed to be set at 500 lbs and later 550 lbs, instead of the prescribed <250 lbs. Staff confirmed the incorrect settings but could not explain the discrepancy, and the facility lacked a policy on pressure ulcer prevention.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis, leading to a lack of post-hemodialysis assessments on multiple occasions. Despite having a care plan and guidelines in place, the facility did not ensure communication sheets were consistently sent and returned, placing the resident at risk of adverse outcomes.
The facility failed to follow physicians' ordered parameters for blood glucose monitoring for two residents, leading to the administration of insulin despite blood glucose levels being below the specified threshold. This placed the residents at risk for complications related to hypoglycemia and unnecessary medication. The facility lacked a policy for medication monitoring, contributing to this deficiency.
A facility failed to provide appropriate dementia care for a resident with schizoaffective disorder and dementia, leading to persistent and escalating behavioral issues. The care plan lacked specific triggers and interventions, and staff had inconsistent knowledge and training on managing the resident's behaviors.
A facility failed to ensure staff reported an allegation of physical abuse immediately to the Administrator. A CNA allegedly smacked a cognitively impaired resident on the hand, and the incident was not reported until three days later. The delay allowed the alleged perpetrator to continue working, placing the resident in immediate jeopardy. The resident's care plan and follow-up assessments were not adequately documented.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). This deficiency was identified during an observation, record review, and interview process. The facility had a census of 29 residents, with one main kitchen and dining area. During an interview, Dietary BB stated that she had not yet taken the test to obtain her dietary manager certification but was scheduled to take it in the future. Additionally, the registered dietician was only available for consultation by phone and visited the facility twice a month to review residents' diets. The facility did not provide a policy regarding the CDM, which contributed to the deficiency and placed residents at risk for unmet dietary and nutritional needs.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility, with a census of 29 residents, was found to have deficiencies in food storage practices during a survey. Observations in the main kitchen revealed several issues that did not comply with professional standards for food service safety. Specifically, a dry, brown-tinged towel was found in front of the coffee maker, and dishes from the previous night were left unwashed in the dishwashing area, which also had a musty odor. In the drink refrigerator, a pitcher of juice or drink was not labeled or dated, and a pitcher of Kool-Aid also lacked a label or date. Additionally, a tray with 12 clear plastic drinking glasses filled with juice and three glasses filled with milk were found without covers, labels, or dates. The condiment refrigerator contained a salad with a date of 10/18/24, but two covered fruit cups and two bowls of applesauce and peaches lacked labels or dates. Dietary staff member BB acknowledged the oversight, stating that she had not yet checked the refrigerators and freezers for unlabeled or undated items that morning. She confirmed that all food items should be dated and labeled when opened or transferred to a new container or sealed bag. Furthermore, she stated that juice and milk glasses should be covered with plastic wrap and dated when stored in the refrigerator. The facility did not provide a policy on food storage, which contributed to the failure to ensure that food items were stored according to professional standards, placing residents at risk of foodborne illness and cross-contamination.
Failure to Conduct Background Checks on New Employees
Penalty
Summary
The facility failed to implement its policy prohibiting the hiring of employees found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This failure was identified during a review of staffing for license verification, in-service training, and background checks. Specifically, the facility did not conduct criminal background checks for two employees, a Licensed Nurse (LN) and a Housekeeping staff member, upon their hire dates. The absence of these checks meant that the facility did not verify whether these employees had any history of abuse, neglect, exploitation, or mistreatment, which is a requirement according to the facility's policy revised in September 2023. The deficiency was discovered when the facility was unable to provide evidence of completed background checks for the two employees. Administrative Staff A acknowledged the oversight and was unsure why the background checks were missing from the employees' files. This oversight allowed the employees to have access to residents without the necessary verification of their backgrounds, placing the residents at risk for potential abuse, neglect, misappropriation, or mistreatment.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, placing seven cognitively impaired, independently mobile residents at risk for preventable accidents and injuries. During an inspection of the 100-hall, it was observed that the restorative room was left unlocked and unsupervised, with several types of multi-purpose cleaners stored in an unlocked cabinet under the sink. These bottles were labeled with warnings indicating they were hazardous to humans, could cause eye irritation, and were harmful if swallowed. A Certified Nurse's Aide acknowledged that the chemicals should be secured or the door should be closed to prevent resident access. An Administrative Nurse confirmed that potentially hazardous cleaning products should be locked up and inaccessible to residents. The facility's Accidents and Fall Management policy, revised in December 2017, requires staff to ensure a safe care environment by addressing potential room hazards, but this was not adhered to in this instance.
Failure to Conduct Proper Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure the proper assessment and management of bed rails for several residents, leading to potential safety risks. Resident 24, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with bed rails despite an assessment indicating they should not be used. The facility did not provide a safety assessment that considered the risks associated with the resident's low air-loss mattress, nor did they obtain informed consent or communicate the risks and benefits to the resident or their representative. Similarly, Resident 5, who had moderate cognitive impairment and required significant assistance, was found to have bed rails without a proper safety assessment. The facility did not document the risks associated with the use of bed rails in conjunction with a low air-loss mattress, nor did they ensure that the resident or their representative was informed about the potential risks and benefits. This lack of documentation and communication placed the resident at risk for uninformed decisions and impaired safety. Residents 17 and 12 also experienced similar deficiencies. Resident 17, who had memory impairments and required assistance for mobility, had a bed cane without a documented safety assessment or informed consent. Resident 12, who was on hospice care and had intact cognition, used a bed cane without a proper safety assessment or documentation of the risks associated with their low air-loss mattress. In both cases, the facility failed to ensure that the residents or their representatives were advised of the risks and benefits of using bed rails, leading to potential safety hazards.
Failure to Provide Wheelchair Foot Pedals for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, had foot pedals on her wheelchair while being pushed by staff, which left her vulnerable to accidents and injuries. R4's medical history included diagnoses of depressive disorder, hypertension, hemiparesis/hemiplegia following a stroke, major depressive disorder, vascular dementia, and anxiety. The resident had a severely impaired cognition with a BIMS score of seven and required supervision or assistance from staff once seated in her wheelchair. Her care plan indicated the need for staff assistance with activities of daily living and specified the use of a wheelchair for transportation. Observations revealed that on two separate occasions, R4 was pushed in her wheelchair without foot pedals, causing her feet to repeatedly bounce on the floor. Staff members, including CNAs and a licensed nurse, acknowledged that residents should have foot pedals when being pushed. However, the facility did not provide a policy on the accommodation of needs, resulting in the failure to provide foot pedals for R4's wheelchair. This oversight constituted a deficiency in meeting the resident's care needs.
Failure to Support Resident Communication and Socialization
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, received supportive care and services to promote and maintain his quality of life. R18, who had a primary language other than English, was not provided with adequate strategies to communicate his wants, needs, or feelings, nor was he encouraged to socialize. Despite having a care plan that included the use of an interpreter and the provision of TV and radio in his native language, these strategies were not consistently implemented. Observations showed that R18 was often left without communication aids, such as a TV or radio in his language, and staff did not engage with him during meals or in common areas. R18's medical history included cerebral infarction, hypertension, diabetes mellitus, depression, cognitive-communication deficit, hemiplegia, vascular dementia, expressive language disorder, and protein-calorie malnutrition. His cognitive abilities were severely impaired, as indicated by a BIMS score of six. Despite having a communication book and access to an interpreter, staff relied on gestures and pointing for communication. The facility did not provide a policy related to maintaining communication and other activities of daily living, which contributed to the resident's risk of decreased quality of life and isolation.
Improper Mattress Settings for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set to the appropriate weight settings as per the physician's order and the resident's current weight. The resident, who had a history of severe cognitive impairment, bilateral upper and lower extremity impairments, and a history of Stage 3 pressure ulcers, was at risk for pressure injuries and skin breakdown. The resident's care plan required the mattress to be set to less than 250 lbs, but observations revealed that the mattress was set to 500 lbs and later to 550 lbs, which was not in accordance with the physician's order. Licensed Nurse G confirmed the incorrect settings but was unaware of the reason for the discrepancy. Administrative Nurse D stated that the mattress settings should be checked each time staff enter the room, suggesting that the control panel might have been accidentally adjusted. The facility was unable to provide a policy related to the prevention of pressure ulcers when requested, indicating a lack of proper documentation and adherence to care protocols.
Inadequate Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication between the facility and a resident's dialysis center, which placed the resident at risk of potential adverse outcomes and physical complications related to dialysis. The resident, who had diagnoses including diabetes mellitus, congestive heart failure, obesity, hypertension, and required dialysis, was documented to have intact cognition and was independent in certain activities of daily living. The resident's care plan included monitoring the dialysis shunt daily and changing dressings as ordered. However, the facility's records lacked evidence of post-hemodialysis assessments for several dates, indicating a lapse in communication and documentation. Licensed Nurse G and Administrative Nurse D confirmed that it was the nurse's responsibility to ensure communication sheets were sent to and returned from the dialysis center. The facility's Dialysis Management Guideline policy required maintaining communication and coordinating care with the dialysis center, including assessing the dialysis access site routinely. Despite these guidelines, the facility did not consistently receive or follow up on communication sheets from the dialysis center, leading to the deficiency in care coordination for the resident receiving dialysis.
Failure to Follow Blood Glucose Monitoring Parameters
Penalty
Summary
The facility failed to adhere to physicians' ordered parameters for blood glucose monitoring for two residents, R10 and R15, which resulted in the administration of insulin despite blood glucose levels being below the specified threshold. For R10, the Electronic Medical Record (EMR) indicated a history of diabetes mellitus, among other conditions, and prescribed insulin with specific instructions to hold the medication if blood glucose levels were below 110 ml/dl. However, the Treatment Administration Record (TAR) showed multiple instances where insulin was administered despite blood glucose readings below this threshold, such as 82 ml/dl and 84 ml/dl. Similarly, R15's EMR documented a diagnosis of diabetes mellitus and prescribed insulin with instructions to hold the medication for blood glucose levels below 110 ml/dl. The TAR recorded several instances where insulin was administered despite blood glucose levels being below the ordered parameters, such as 94 ml/dl and 104 ml/dl. Interviews with nursing staff confirmed that it was their responsibility to verify blood glucose levels and administer or hold insulin accordingly, yet the facility did not provide a policy for unnecessary medication or medication monitoring. The failure to follow the ordered parameters for blood glucose monitoring placed both residents at risk for complications related to hypoglycemia and unnecessary medication. The facility's lack of a policy for medication monitoring contributed to this deficiency, as evidenced by the repeated administration of insulin outside the prescribed parameters for both residents.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident diagnosed with schizoaffective disorder and dementia with behavioral disturbances. The resident exhibited moderate cognitive impairment, hallucinations, delusions, and various behavioral symptoms, including wandering, verbal outbursts, and inappropriate physical contact with staff and other residents. Despite these behaviors, the facility did not adequately assess, identify, record, respond to, or reassess the resident's specific behaviors and triggers to support his individualized care needs. The resident's care plan included several interventions to manage his behaviors, such as discussing inappropriate behavior, cuing appropriate requests, ensuring staff attention before starting care, and encouraging verbal expression instead of physical contact. However, the care plan lacked evidence of specific triggers related to the resident's behaviors. Multiple incidents were documented where the resident grabbed or touched staff and other residents inappropriately, and staff attempted various redirection strategies, including providing snacks and one-on-one supervision. Despite these efforts, the resident's behaviors persisted and escalated over time. Interviews with staff revealed inconsistent knowledge and training regarding the resident's triggers and appropriate behavioral interventions. Some staff members were aware of certain triggers, such as the resident's desire for coffee or snacks, while others were not. Additionally, not all staff had received behavioral health or dementia training. The facility's policy on behavior management and psychotropic medications required individualized care plans with specific triggers and interventions, but this was not adequately implemented for the resident. The facility's failure to properly assess and manage the resident's behaviors affected his ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure staff identified and reported an allegation of physical abuse immediately to the Administrator as required. On 02/09/24, a Certified Nurse Aide (CNA) allegedly smacked a severely cognitively impaired resident on the hand after the resident hit the CNA during peri-care. Another CNA witnessed the incident but did not report it immediately to the Administrator, instead mentioning it to another CNA and later writing a Report of Concern three days after the incident. The delay in reporting allowed the alleged perpetrator to continue working in the facility, placing the resident in immediate jeopardy. The resident involved had significant cognitive impairments, including short and long-term memory problems, and communicated primarily through gestures and noises due to being non-verbal and deaf. The resident's care plan directed staff to communicate clearly and observe the resident's facial expressions and gestures. Despite these directives, the incident occurred, and the resident's electronic medical record lacked documentation of follow-up assessments to monitor the resident's ongoing psychosocial wellbeing after the alleged abuse. The facility's investigation revealed that the CNA who witnessed the abuse did not report it immediately, and the alleged perpetrator was not interviewed during the investigation. Witness statements from other staff indicated that they were unaware of the incident until the Report of Concern was submitted. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents to the Administrator, which was not followed in this case, leading to a citation for past noncompliance at the scope and severity of J.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Kansas City | 1.1 mi | ★★★★★ | 20 | 0 |
| Riverbend Post Acute Rehabilitation | 1.8 mi | — | 33 | 0 |
| Providence Place | 3 mi | ★★★★★ | 16 | 0 |
| The Healthcare Resort Of Kansas City | 3.1 mi | ★★★★★ | 32 | 0 |
| Pinnacle Point Wellness & Rehabilitation | 6.6 mi | ★★★★★ | 13 | 0 |
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