Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Willow Ridge Nursing And Rehabilitation Center,llc during CMS and state inspections, most recent first.
Failure to Provide Written Advance Directive Information: The facility failed to provide written information needed to formulate an advance directive for 5 of 5 residents reviewed. Records showed that each resident had a Resident Rights/Advanced Directive form, but the forms lacked the required written information, and the Admissions Director acknowledged the omission during interview.
A resident continued receiving Tobramycin ophthalmic ointment for a stye even after the eye condition had healed. The MAR showed the medication was administered for months beyond the original order, progress notes did not address the issue after the initial period, and an NP stated she was unaware the medication was still being given. An LPN confirmed the resident was still receiving the eye medication.
Pureed Diet Menu Not Followed at Lunch: A dietary worker did not prepare the pureed strawberry cookie bar listed on the approved lunch menu for residents on a pureed diet. Surveyors observed that the residents did not receive the dessert, and the Dietary Supervisor confirmed the menu item should have been served but was not.
A resident with multiple diagnoses, including dementia and anxiety, was admitted to hospice per physician's orders, but the facility did not develop or implement a care plan addressing hospice care. This lack of a hospice care plan was confirmed by both an LPN and the DON during interviews.
A resident with multiple chronic conditions was started on oxygen therapy, but the responsible party was not notified of this change. The LPN who initiated the oxygen confirmed the lack of notification, and the DON acknowledged the omission.
A facility failed to ensure a resident remained free from accident hazards by not investigating incidents involving a laptray on a gerichair. Despite the resident's high fall risk and frequent removal of the laptray, no incident reports were completed, and the laptray continued to be used. Staff acknowledged the resident's behavior, but the care plan did not reflect these incidents, leading to a deficiency.
A resident with severe cognitive impairment was observed using a geri chair as a restraint without a properly completed Physical Restraint Informed Consent. The form lacked documentation of alternative approaches, consent indication, and staff completion details. The DON confirmed these omissions.
A resident with intact cognition felt embarrassed after a CNA discussed his private parts and incontinence issues in front of other staff members outside the facility. The incident was confirmed by a former wound care nurse and reported by the resident's sister, leading to acknowledgment by the executive director of the breach of the resident's rights to dignity and privacy.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information needed to formulate an advance directive for 5 of 5 residents reviewed for advance directives, including Residents #2, #8, #23, #71, and #116. Review of the records showed that each resident had a Resident Rights/Advanced Directive form, but the forms failed to include written information to formulate an advance directive. Resident #2 was admitted on 02/17/2025 and had a Resident Rights/Advanced Directive form dated the same day without the required written information. Resident #8 was admitted on 04/08/2025 and had an undated form signed by a representative that also lacked the written information. Resident #23 was admitted on 10/30/2024 and had a form dated 04/29/2024 without the required information. Resident #71 was admitted on 03/24/2022 and had a form dated 03/23/2022 without the required information. Resident #116 was admitted on 10/02/2024 and had a signed form dated the same day that also failed to provide written information to formulate an advance directive. During interview, the Admissions Director acknowledged that these residents' forms failed to include and provide the required written information.
Unnecessary Ophthalmic Antibiotic Continued After Stye Resolved
Penalty
Summary
The facility failed to ensure that Resident #8's drug regimen was free from unnecessary drugs when Tobramycin ophthalmic ointment continued after the indication for use had been resolved. Resident #8 was admitted with diagnoses including hordeolum externum of the left eyelid, type 2 diabetes mellitus without complications, and end stage renal disease. A physician order dated 05/13/2025 started Tobramycin ophthalmic ointment 0.3% for a stye of the left upper eyelid, with instructions to apply it every 8 hours until healed. Review of the MARs for May through September 2025 showed the medication was still being administered until 09/17/2025. The progress notes after 05/28/2025 did not address the hordeolum externum, and an observation on 09/16/2025 showed the resident's left eye looked normal and without issue. During interview, the NP stated she was aware the stye had healed and was unaware the resident was still receiving Tobramycin, and said she would typically have discontinued the order once the stye resolved. An LPN confirmed the resident was still receiving the medication.
Pureed Diet Menu Not Followed at Lunch
Penalty
Summary
The facility failed to follow the approved pureed menu for 10 residents who had orders for a pureed diet. The 09/15/2025 lunch menu, reviewed and approved by the Registered Dietician, specified pureed Southwestern chicken over pureed rice and gravy, pureed black eyed peas, and pureed strawberry cookie bar for residents requiring a pureed diet. During observation of the lunch meal service at 11:55 a.m., surveyors found that the 10 residents on a pureed diet did not receive the pureed strawberry cookie bar for dessert. At 12:15 p.m., the dietary worker confirmed he was responsible for preparing the pureed menu and stated he did not puree the cookie bar as listed on the menu. At 12:20 p.m., the Dietary Supervisor confirmed the residents should have received the dessert listed on the menu and that they did not receive a dessert during the lunch meal. At 12:45 p.m., the Administrator was informed that the residents on a pureed diet did not receive the dessert specified on the facility menu for lunch.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing hospice care for one resident who had been admitted to hospice. Record review showed that the resident, who had diagnoses including unspecified dementia, psychotic disturbance, anxiety, and senile degeneration of the brain, was admitted to hospice per physician's orders. However, the comprehensive plan of care did not include any problems or approaches related to hospice care. This omission was confirmed during interviews with both an LPN and the DON, who acknowledged that a hospice plan of care should have been initiated when the resident was placed on hospice.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party (RP) of a significant change in the resident's condition, specifically the initiation of oxygen therapy. The resident, admitted with diagnoses including senile degeneration of the brain, unspecified dementia with agitation, anxiety disorder, hypertension, osteoarthritis, and unspecified pain, was started on 3.5 liters of oxygen via nasal cannula as documented in a progress note. Review of the medical record did not show evidence that the RP was informed of this change. Interviews confirmed that the LPN who initiated the oxygen did not notify the RP, and the DON acknowledged that notification should have occurred. The RP also reported not being informed about the initiation of oxygen therapy.
Failure to Address Laptray Safety Hazard
Penalty
Summary
The facility failed to ensure that a resident remained as free from accident hazards as possible, specifically regarding the use of a laptray on a gerichair. Resident #92, who was admitted with diagnoses including restlessness, agitation, and unspecified dementia, was observed multiple times in a gerichair with a laptray. Despite being at high risk for falls, the facility did not conduct thorough investigations after incidents involving the resident's laptray, nor did they document these incidents in the Incident/Accident report log. Observations and interviews revealed that the resident frequently removed the laptray and attempted to crawl out of the gerichair, indicating a potential safety hazard. Staff members, including LPNs and CNAs, acknowledged that the resident had previously slipped under the laptray and continued to remove it. However, no incident reports were completed, and the facility continued to use the laptray despite these occurrences. The facility's failure to document and investigate these incidents was confirmed by the Director of Nursing and the Clinical Operations Consultant. The resident's care plan did not reflect the incidents involving the laptray, and there was no evidence of interventions to address the resident's behavior of sliding out of the gerichair. This lack of documentation and continued use of the laptray without proper investigation contributed to the deficiency.
Incomplete Physical Restraint Informed Consent for Resident
Penalty
Summary
The facility failed to have a completed Physical Restraint Informed Consent for a resident who was observed using a geri chair as a restraint. The resident, who had severe cognitive impairment and required extensive assistance with all activities of daily living, was admitted with multiple diagnoses including essential hypertension, seizures, and hemiplegia following a cerebral infarction. Observations revealed the resident was placed in a geri chair with the head and lower extremities elevated, and the facility had an order to monitor the resident in this position due to poor body control related to a cerebrovascular accident. Upon review, it was found that the Physical Restraint Informed Consent form was incomplete. The section for least restrictive, alternative non-restraint approaches was left blank, and the consent section was not marked to indicate whether the responsible party consented or did not consent to the use of the restraint. Additionally, the form lacked the name and relationship of the representative, as well as the staff member who completed the form. The Director of Nursing confirmed these omissions and acknowledged that the form was not properly completed.
Breach of Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident by allowing a staff member to discuss the resident's private medical condition in a public setting. The incident involved a resident with intact cognition, who had a history of cardiovascular accident, diabetes, and other chronic conditions. The resident reported feeling embarrassed and sad after a certified nursing assistant (CNA) discussed the size of his private parts and incontinence issues in front of other female staff members while the resident was outside the facility. The CNA admitted to making comments about the resident's private parts in the presence of other staff members, which was confirmed by a former wound care nurse who witnessed the conversation. The resident's sister, who is also a CNA, found the resident visibly upset after the incident and reported it to the director of nurses. The facility's executive director acknowledged that the CNA should not have discussed the resident's private matters in a public setting, indicating a breach of the resident's rights to dignity and privacy.
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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 Arcadia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Leslie Lakes Retirement Center | 0.5 mi | ★★★★★ | 10 | 0 |
| Alpine Skilled Nursing And Rehabilitation | 13.4 mi | ★★★★★ | 6 | 0 |
| Presbyterian Village Of Homer | 16.5 mi | ★★★★★ | 0 | 0 |
| Princeton Place-ruston | 16.6 mi | ★★★★★ | 6 | 0 |
| Ruston Nursing And Rehabilitation Center, Llc | 20.4 mi | ★★★★★ | 1 | 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.