Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 The Willows At Fritz Farm during CMS and state inspections, most recent first.
Care Plan Not Revised After Wheelchair Seat Belt Discontinued: A resident with COPD, intact cognition, and fall risk status had a wheelchair Velcro seat belt order discontinued, but the care plan still listed the belt as an active intervention. Observations showed the resident in a wheelchair without the belt, and interviews with the resident and staff confirmed the belt was no longer in use while the care plan remained outdated.
Medication storage and labeling were not maintained for two residents’ medications. An RN and KMA found eye drops without proper opened dates, an unopened insulin pen stored in a cart instead of the refrigerator, and two unopened vials of stock heparin kept in the same cart compartment as ophthalmic solutions. Staff and the contracted pharmacist confirmed that opened multi-use meds should be dated and that insulin and stock heparin had specific storage requirements.
An LPN failed to sanitize her hands while serving meals and providing feeding assistance to three residents who required help with meals, and she used the same unsanitized hands between residents. She also drank from a personal cup at the table and rubbed her hand across her face before continuing resident care. The facility policy required hand hygiene before and after direct resident contact and before and after preparing or serving meals and drinks, and the DHS stated staff were expected to sanitize hands between residents and not eat or drink in resident care areas.
Persistent urine odors and inadequate management of urinary catheter leakage in one hallway resulted in a failure to maintain a clean, comfortable, and homelike environment. A resident with a catheter experienced frequent leakage, leading to soiled carpets and lingering odors despite cleaning efforts. Staff and family interviews confirmed inconsistent use of containment measures and improper closure of the catheter drainage bag, contributing to the ongoing issue.
Surveyors found that food items in a nourishment refrigerator, including pimento cheese, yogurt, supplement shakes, and other products, were not properly labeled with resident names, received dates, or staff initials as required by facility policy. Staff interviews revealed confusion about labeling responsibilities and a lack of clarity regarding which food items belonged to which residents, resulting in a deficiency for not following professional food service standards.
The facility did not consistently inform or provide written information to residents about their rights to accept or refuse treatment or to formulate advance directives. For three residents, there was no evidence in the medical record that the facility had requested or obtained copies of legal documents such as a POA or living will, despite residents or families stating these documents existed. Staff interviews confirmed inconsistent follow-up and documentation regarding advance directive paperwork.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols during high-contact care and medication administration for two residents, including not wearing required PPE when repositioning a resident with a pressure ulcer and handling medications without proper hand hygiene or discarding dropped pills, despite clear facility policies and posted signage.
Care Plan Not Revised After Wheelchair Seat Belt Discontinued
Penalty
Summary
The facility failed to revise the comprehensive care plan for R20 after a Velcro lap belt order was discontinued. R20’s care plan, dated 02/17/2020, still listed an active intervention for a self-releasing Velcro seat belt for falls, even though the physician order for the seat belt had been discontinued on 12/27/2025. The facility policy stated that if a previous care plan was no longer needed, it would be resolved from the active care plan. R20 was admitted with COPD with exacerbation and had an annual MDS showing a BIMS score of 15 out of 15, indicating intact cognition. The MDS also showed she used a wheelchair for mobility, required partial assistance to self-propel up to 50 feet due to a respiratory diagnosis, was a fall risk, and had experienced a fall since admission. Observations on 05/12/2026, 05/13/2026, and 05/14/2026 showed R20 in a wheelchair without a self-releasing seat belt attached. During interview, R20 stated she did not want the seat belt because she was able to make her own decisions and did not like it. Staff interviews confirmed the care plan was expected to reflect current orders, and the MDS Nurse and DHS stated care plans were updated based on reviewed orders and should be accurate and current.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored safely, securely, and in accordance with labeling and storage requirements for medications belonging to two residents, R48 and R32. During observation of the 300 Hall medication cart, R48’s brimonidine 0.2% eye drops had a date on the box but not on the bottle, a second bottle of brimonidine 0.2% eye drops had no date on either the package or bottle, and azelastine 0.05% eye drops had no date on the box or bottle. The facility policy required multi-use medications to be dated when opened and for no expired medication to be administered. The observation also found R32’s unopened Amdelog insulin pen, which was labeled for refrigeration when unopened, stored in the medication cart instead of the refrigerator. In the same compartment as the ophthalmic solutions, two unopened vials of stock heparin were observed in a medication cup in the top drawer of the cart. Staff interviews confirmed that opened multi-use medications should be dated, unopened insulin should be refrigerated, and stock heparin should be stored in the medication room rather than in the cart. The pharmacist stated the facility was responsible for storing medications according to instructions and dating opened containers, and the DHS stated she expected staff to label opened vials and store unopened insulin in the refrigerator.
Hand Hygiene Failure During Meal Assistance
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents reviewed for meal service. During observation of the midday meal service, an LPN gave out multiple plates of food without washing or sanitizing her hands between residents and then provided hands-on feeding assistance to three residents using the same unsanitized hands. She also drank from a personal cup at the table while assisting residents, and after taking a drink she rubbed her hand across her nose/mouth area before continuing to provide resident care without cleaning her hands. The residents involved were R23, R39, and R52. R23 had Parkinsons disease and required staff assistance with all personal needs, including meals. R39 had diagnoses of dementia and rheumatoid arthritis and also required staff assistance with all personal needs, including meals. R52 had dementia and required staff assistance with all personal needs, including meals. The facility policy on hand hygiene stated that health care workers shall use hand hygiene before and after direct physical contact with residents and before and after preparing or serving meals and drinks. During interview, the LPN stated she did not think her drink at the table was a problem and could not explain why she continued resident care after wiping her face without cleaning her hands. The DHS stated staff were expected to wash or sanitize hands before feeding assistance and between residents and that staff were not permitted to eat or drink in resident care areas while residents were being assisted.
Failure to Maintain Clean and Homelike Environment Due to Catheter Leakage and Odor
Penalty
Summary
The facility failed to provide a clean, sanitary, comfortable, and homelike environment for residents in the 100 Hall, as evidenced by persistent urine odors and inadequate management of urinary catheter leakage. Multiple observations over several days revealed a recurring urine smell in the hallway, front lobby, and a specific resident room, even after attempts to clean and shampoo the carpet. Documentation and interviews confirmed that a resident with a urinary catheter experienced frequent leakage, which resulted in urine soiling the carpet. Family members and staff reported that towels and dignity covers were sometimes used to contain the leakage, but these measures were not consistently effective, and the odor persisted. Staff interviews indicated that the resident involved often refused catheter care and assistance with changing soiled clothing, contributing to the ongoing issue. It was also determined that improper closure of the catheter drainage bag by an aide led to leakage incidents. Despite efforts by Environmental Services to clean the affected areas, the urine odor remained, and the carpet required replacement. The facility did not provide a policy specifically addressing the maintenance of a homelike environment, and the ongoing odor issue was acknowledged by both nursing and administrative staff as a dignity concern for residents.
Failure to Properly Label and Identify Resident Food Items in Nourishment Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically in the nourishment refrigerator near the 300 Hallway. Observations revealed multiple food items, including opened tubs of pimento cheese, yogurt containers, supplement shakes, an oral rehydration solution, Med Pass supplements, and a jar of olives, that were not properly labeled with resident names, received dates, or staff initials as required by the facility's policy. Some items only had partial labeling, such as received dates and staff initials, but lacked resident identification. The facility's policy required all food items brought in for residents to be labeled with the resident's name, received date, production date, use by date, and staff initials. Interviews with staff, including a Certified Registered Care Aide, RN, Assistant Director of Health Services, Director of Health Services, and Director of Dietary Services, confirmed a lack of clarity and consistency regarding responsibility for labeling and identifying food items. Several staff members were unsure to whom the food items belonged, and the Director of Dietary Services stated it was not his responsibility to label items with resident names. The Executive Director acknowledged there was no specific policy for food brought by family, only a general labeling policy, and was unaware that all foods in the residents' refrigerator should have a resident's name. This lack of proper labeling and identification led to the deficiency cited by surveyors.
Failure to Provide and Document Advance Directive Information for Residents
Penalty
Summary
The facility failed to inform and provide written information to all adult residents regarding their right to accept or refuse medical or surgical treatment and to formulate an advance directive, as required by regulation. For three of six residents reviewed, there was no evidence in the medical records that the facility had requested or obtained copies of legal documents such as a power of attorney (POA) or living will, despite residents or their families stating these documents existed. Documentation in the electronic health records was limited to code status, with no supporting legal paperwork or evidence that advance directive information was provided or discussed in detail at admission. One resident with severe cognitive impairment was admitted with a family member listed as POA, but the facility did not have a copy of the legal POA document in the record and could not provide it upon request. Another resident, moderately cognitively impaired, and her family indicated that a living will existed and had been discussed with the facility at admission, but no documentation of the living will was found in the chart. A third resident, cognitively intact, stated she had a living will and believed her son had provided it, but again, there was no evidence in the record that the facility had received or documented the living will or provided information about it. Interviews with facility staff, including the Admissions Coordinator, DON, and Executive Director, revealed that while there were processes in place to discuss advance directives at admission and during care plan meetings, there was a lack of consistent follow-up and documentation. Staff acknowledged that communication and follow-up with families regarding advance directive paperwork needed improvement, and that documentation of these discussions and receipt of legal documents was not always completed or tracked effectively.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in adherence to Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, an LPN and a nursing student were observed providing high-contact care to a resident with a pressure ulcer, who was under EBP, by pulling the resident up in bed while wearing only gloves and not donning the required gown. This action was inconsistent with both the facility's EBP policy and the CDC-based signage posted on the resident's door, which specified that both gown and gloves must be worn during high-contact care activities for residents with wounds. Interviews with staff revealed inconsistent understanding and application of EBP requirements, with some staff believing gowns were only necessary for wound care and not for other direct care activities such as repositioning a resident in bed. Another deficiency was observed during medication administration. An LPN dropped a pill onto the medication cart, picked it up with an ungloved hand, and placed it into a medication cup with other pills for a resident, rather than discarding the pill as required by policy. Shortly after, the same LPN donned gloves to administer insulin without performing hand hygiene beforehand, contrary to the facility's hand hygiene and medication administration policies. Interviews with the LPN and other staff confirmed a lack of adherence to proper hand hygiene and medication handling protocols, with some staff unaware that dropped pills should be discarded and that hand hygiene is required before donning gloves. The residents involved included one with a stage three pressure ulcer and multiple comorbidities, who had physician orders and a care plan specifying the use of EBP during high-contact care, and another resident with dementia, epilepsy, and diabetes who required medication administration. The observed failures to follow established infection control policies and procedures occurred despite the presence of clear facility policies, posted signage, and staff education on EBP and hand hygiene. These lapses were confirmed through direct observation, record review, and staff interviews.
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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 Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sayre Christian Village Nursing Home | 1.3 mi | ★★★★★ | 0 | 0 |
| Mayfair Manor | 2.4 mi | ★★★★★ | 7 | 0 |
| Hartland Park Health & Rehabilitation | 2.9 mi | ★★★★★ | 4 | 0 |
| Bluegrass Care & Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Lexington Country Place | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.