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 Willard Care Center during CMS and state inspections, most recent first.
The facility did not ensure that families or responsible parties were notified or that notification was documented after significant events such as falls, injuries, medication changes, and altercations involving several residents with cognitive impairments and complex medical needs. Despite care plans and staff interviews confirming the requirement for such notifications, there was no evidence in the records that these communications occurred.
A resident with multiple complex medical conditions received ferrous sulfate daily for 82 days instead of the physician-ordered weekly dose, due to a medication order entry error and lack of detection by staff. The eMAR displayed the correct frequency, but it was not prominently visible, leading to daily administration of the iron supplement while vitamin C was given as ordered. Staff interviews confirmed the process breakdown in identifying and correcting the discrepancy.
The facility did not follow through on RD recommendations for nutritional supplements and fortified foods for several residents with wounds and those identified as underweight. Despite documented weight loss, poor intake, and the presence of pressure ulcers, staff failed to provide prescribed supplements such as Pro-Stat, Boost Breeze, and super cereal. Communication lapses and inconsistent documentation led to delays in implementing dietary changes, resulting in residents not receiving the recommended nutritional support.
The facility failed to maintain an ongoing program of meaningful activities for all residents after the departure of the Activity Director, resulting in multiple days without scheduled activities, lack of documentation, and unmet individual interests for two residents. Staff interviews confirmed that activities were sporadic, documentation was missing, and residents expressed dissatisfaction and boredom due to the lack of engagement.
Staff failed to report allegations of possible abuse involving two residents, one of whom had significant behavioral disturbances and physically interacted with a roommate in a potentially harmful manner. Despite facility policy requiring immediate reporting of such incidents to DHSS, there was no documentation or evidence that the events were reported as required. Interviews revealed confusion among staff regarding what constitutes reportable abuse, leading to a deficiency in mandated reporting.
Staff did not complete or document investigations into multiple incidents of possible resident-to-resident abuse, including physical altercations and unwelcome contact involving two residents with cognitive impairments. Despite facility policy requiring prompt investigation and reporting to DHSS, no formal investigation or report was made, and interviews revealed gaps in communication and follow-through among staff and administration.
A resident admitted with stage 2 pressure ulcers did not have wound care orders obtained or documented, and staff failed to consistently document wound assessments, treatments, or physician notifications. Despite facility policy requiring prompt assessment and physician notification for wounds, there was no evidence of ongoing care or follow-up for the resident's pressure ulcers, as confirmed by staff interviews and record review.
A resident's laptop went missing after a room change in an LTC facility. Despite being listed on the resident's inventory of personal effects, the laptop could not be located. The resident, who was cognitively intact, reported the laptop missing after the move. Facility staff confirmed the laptop's absence, and the investigation did not document a report to law enforcement or comprehensive interviews to conclude the matter.
A facility failed to report a resident's missing laptop to the State Survey Agency within the required 24-hour timeframe. The resident, who was cognitively intact, reported the missing item to the Housekeeping Supervisor, who informed the Administrator. However, the Administrator delayed reporting to DHSS and did not notify law enforcement, citing corporate advice. Staff interviews revealed confusion about reporting requirements, contributing to the deficiency.
A resident reported a missing laptop, but the facility failed to conduct a timely and thorough investigation as per its policy. The investigation lacked documentation of staff and resident interviews, and no police report was filed. The resident was dissatisfied with the facility's response, and staff interviews revealed inconsistencies in the investigation process.
Failure to Notify Family or Responsible Party of Resident Condition Changes and Events
Penalty
Summary
The facility failed to ensure timely and documented notification to residents' families or responsible parties regarding changes in condition, falls, injuries, and new physician orders for multiple residents. Review of records for four residents revealed that staff did not document family or responsible party notification after significant events, including the initiation and discontinuation of antibiotics, multiple falls resulting in bruises or head injuries, and involvement in altercations. In each case, the residents' care plans specifically required staff to notify family and physicians of such changes, but there was no evidence in the progress notes that this communication occurred. For example, one resident with dementia and on hospice care received new and discontinued antibiotic orders for cellulitis, but there was no documentation that the family or responsible party was notified of these medication changes. Another resident, also with dementia and a history of repeated falls, experienced several falls resulting in bruises and head injuries, yet staff failed to document any notification to the family or responsible party after each incident. Similarly, a resident with COPD and diabetes was found at the foot of the bed, and another resident with dementia was involved in a physical altercation and a separate fall, but in both cases, there was no documentation of family notification. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the DON, and the Administrator, confirmed that the expectation was for nursing staff to notify families or responsible parties of any changes in condition, falls, or new orders, and to document this communication in the progress notes. However, the facility did not have a specific written policy regarding notification, and staff acknowledged that if notification was not documented, it was considered not done. The lack of documentation and failure to notify families or responsible parties as required by care plans and resident rights constituted the deficiency.
Medication Administration Error: Incorrect Frequency of Iron Supplement
Penalty
Summary
The facility failed to prevent a significant medication error by administering a resident's ferrous sulfate (iron supplement) at an incorrect frequency for 82 days. The physician's order, as documented in both the hospital discharge summary and the facility's physician order sheet, specified that the resident should receive ferrous sulfate once weekly on Fridays, in conjunction with vitamin C. However, review of the electronic Medication Administration Record (eMAR) showed that staff administered the ferrous sulfate daily instead of weekly, while the vitamin C was given as ordered on Fridays. The error originated from the process of entering physician orders into the facility's system. The charge nurse was responsible for inputting the orders into the Physician Order Sheet (POS), which then automatically populated the eMAR. Both Certified Medication Technicians (CMTs) and the Director of Nursing (DON) confirmed that the eMAR displayed the ordered frequency, but this information was not prominently visible on the administration screen. As a result, staff did not notice the discrepancy between the ordered and administered frequency, and the medication was given daily without interruption. Interviews with staff revealed that the process for identifying and clarifying order discrepancies was not effectively followed. CMTs stated they should notify the charge nurse or DON if they noticed any discrepancies, but in this case, the daily administration of ferrous sulfate continued unchecked. The DON and Administrator acknowledged that the frequency information was not easily noticeable on the eMAR, contributing to the prolonged error. The resident involved had multiple complex diagnoses, including atrial fibrillation, severe protein-calorie malnutrition, and emphysema, and was at risk for inadequate nutrition and ineffective breathing patterns.
Failure to Implement RD Nutritional Recommendations for Residents with Wounds and Weight Loss
Penalty
Summary
The facility failed to ensure that all residents maintained acceptable parameters of nutritional status by not following up and implementing Registered Dietitian (RD) recommendations for several residents with wounds and those identified as underweight. Specifically, the facility did not act on RD recommendations for protein and calorie supplementation for residents with pressure ulcers and significant weight loss. For example, one resident with a stage 4 pressure ulcer and morbid obesity was recommended to receive Pro-Stat to support wound healing, but this was not ordered or provided. Another resident with chronic illnesses and a very low BMI was recommended to receive super cereal and house shakes due to poor intake and weight loss, but these supplements were not provided until much later, despite ongoing poor meal consumption. Multiple residents with complex medical histories, including dementia, anemia, cerebral palsy, and malnutrition, experienced significant weight loss or had wounds requiring enhanced nutritional support. The RD made specific recommendations for supplements such as Boost Breeze, VHC, and Pro-Stat, but these were not implemented in a timely manner. Staff interviews revealed a lack of awareness of the RD's recommendations, and dietary staff were not preparing or serving the recommended supplements. Documentation systems, such as diet order slips and meal tray cards, were inconsistent and not updated to reflect current dietary orders or supplements, leading to further confusion and lack of implementation. Communication breakdowns were evident between the RD, DON, Dietary Manager, and Administrator. The RD sent recommendations via email, but the DON did not consistently review or act on them, and the Dietary Manager was not always informed of changes. There was no formal process to ensure RD recommendations were reviewed and implemented promptly, and weight loss meetings were not held regularly. As a result, residents at risk for malnutrition, weight loss, and poor wound healing did not receive the necessary nutritional interventions as recommended by the RD.
Failure to Provide Ongoing Activity Program and Documentation
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and physical, mental, and psychosocial well-being of all residents. Observations, record reviews, and interviews revealed that there were significant lapses in the provision and documentation of meaningful activities for residents, including two specific individuals. The activity calendar showed multiple days with no scheduled activities, and on days when activities were listed, essential details such as times were often missing. Staff interviews consistently indicated that since the departure of the Activity Director (AD), there had been a lack of organized activities, with only sporadic events such as pet therapy or church visits occurring, and no consistent staff member assigned to coordinate or document activities. For one resident with diagnoses including epilepsy, diabetes, and peripheral vascular disease, the care plan indicated preferences for activities such as flea market shopping, outings, bingo, and watching television. However, there was no documentation of activity attendance or progress notes by the AD for this resident over a period of more than a month. The resident and staff reported that the resident complained about the lack of activities, expressed feelings of boredom, and stated that their quality of life had diminished due to the absence of activities. The resident's preferences for customary routines and activities were not completed in the assessment, and the facility was unable to provide any documentation of participation in activities during the review period. Another resident, diagnosed with dementia, anemia, and heart failure, also had no documentation of activity attendance or progress notes by the AD. The care plan referenced general involvement in activities but did not address the resident's specific interests, such as movies and bingo, which the resident stated they enjoyed. Staff interviews confirmed that the facility lacked the necessary equipment to play movies and that no one was assigned to ensure activities were provided. Multiple staff members, including CNAs, nurses, and the DON, acknowledged the absence of an AD and the lack of consistent activities, with some staff attempting to provide occasional activities but lacking time and resources. The Administrator confirmed the deficiency, noting that activities were not being completed as often as desired and that documentation was lacking.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported to the state survey agency (DHSS) within the required time frame, as mandated by both state and federal regulations and the facility's own abuse and neglect policy. Specifically, staff did not report incidents involving two residents, one of whom exhibited significant behavioral disturbances, including yelling, cursing, entering other residents' rooms, and physically interacting with a roommate in a manner that included placing a tied gown around the roommate's head and neck. Despite these events, there was no documentation or evidence that the incidents were reported to DHSS as required. Resident #1 had a history of dementia, psychosis, agitation, and other behavioral symptoms, and was noted to have moderate cognitive impairment with episodes of delusions and disorganized thinking. On one occasion, staff found this resident on the bed of a roommate, straddling the roommate and pressing a tied gown against the roommate's neck. Staff intervened, removed the resident, and sent the resident to the hospital for evaluation. However, the incident was not reported to DHSS, and there was no documentation of such a report in either facility or DHSS records. Interviews with staff revealed a lack of consensus on whether the incident constituted abuse and a failure to recognize the need for immediate reporting. The facility's policy clearly states that all allegations of abuse, neglect, exploitation, or mistreatment must be reported immediately, with specific timeframes for reporting depending on the severity of the incident. Despite this, staff interviews indicated confusion about what constitutes reportable abuse, particularly in cases involving residents with dementia. The DON and Administrator both stated that, had they been fully aware of the details, they would have reported the incident to DHSS, but the required reporting did not occur. This failure to report allegations of possible abuse represents a deficiency in the facility's compliance with mandated reporting requirements.
Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were fully and timely investigated, specifically in cases involving two residents. According to the facility's abuse policy, any reports of abuse, including resident-to-resident incidents, must be promptly and thoroughly investigated, with findings reported to administration and the Department of Health and Senior Services (DHSS). However, documentation and interviews revealed that staff did not complete or document investigations for multiple incidents involving one resident exhibiting aggressive and disruptive behaviors toward another resident, including physical altercations and unwelcome contact. One resident, with a history of dementia, psychosis, agitation, and behavioral disturbances, was involved in several incidents where they entered other residents' rooms, yelled, cursed, and physically interacted with their roommate. On one occasion, staff found this resident on top of their roommate, pressing a tied hospital gown against the roommate's neck. Staff intervened, removed the resident, and sent them to the hospital, but did not document or report an investigation of this incident as possible abuse to DHSS. Progress notes and interviews confirmed repeated behavioral issues, including attempts to bite and hit staff, and further unwelcome interactions with other residents, yet no investigation was documented or submitted. Interviews with staff, including CNAs, nurses, the DON, and the administrator, indicated a lack of clarity and follow-through regarding the reporting and investigation process for these incidents. While staff intervened to stop the behaviors and notified supervisors, there was no evidence that a formal investigation was conducted or that the incidents were reported to DHSS as required by policy. The administrator and DON both stated that, had they been fully aware of the details, they would have reported the incidents, but records show that no such investigation or report was made.
Failure to Obtain and Document Wound Care Orders for Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate care and documentation for a resident who was admitted with stage 2 pressure ulcers on the buttocks. Upon admission, the resident had multiple medical conditions, including a fractured rib, altered mental status, diabetes, and severe cognitive impairment, and was dependent on staff for all activities of daily living and bed mobility. The resident was identified as being at risk for developing pressure ulcers and had one or more unhealed pressure ulcers at stage 1 or higher, with a stage 2 ulcer present upon admission. The facility's policies required prompt assessment, documentation, and physician notification for wounds, as well as obtaining and implementing wound care orders. Despite these requirements, staff did not obtain or document physician orders for the treatment of the resident's stage 2 pressure ulcers. There was no evidence in the medical record, including the Medication Administration Record (MAR) and wound management documentation, that wound care treatments were completed or that measurements of the wounds were recorded. Progress notes indicated that staff cleansed and dressed the wounds initially, but there was no follow-up documentation of ongoing care or physician notification for treatment orders. Interviews with staff, including CNAs, LPNs, RNs, the MDS Coordinator, the DON, and the Administrator, confirmed that no wound care orders were obtained or documented, and that the responsibility for obtaining such orders was not fulfilled. The lack of a system to ensure timely physician notification, obtain and implement wound care orders, and document and track wound care led to a failure to provide care in accordance with standards of practice. Staff interviews revealed a general understanding of the process for reporting and assessing new wounds, but in this case, the necessary steps were not taken or documented. The facility's failure to follow its own wound care protocol and admission checklist resulted in incomplete and untimely care for the resident's pressure ulcers.
Resident's Laptop Missing After Room Change
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when the resident's laptop, listed on their inventory of personal effects, could not be located. The resident, who was cognitively intact and required minimal assistance with activities of daily living, reported the laptop missing after a room change. The laptop was initially stored in the resident's closet, covered by long dresses, but was not found after the move. The resident did not witness the laptop being taken and was unsure of when it went missing. The facility's investigation revealed that the laptop was reported missing to the housekeeping supervisor during the room change. The resident's belongings, including the laptop box, were moved on a dolly, but it was unclear if the laptop was inside the box at the time. The Business Office Manager and other staff members confirmed the laptop was not found in the new room, and attempts to contact the resident's family for further information were unsuccessful. Interviews with facility staff, including the housekeeping supervisor, Business Office Manager, MDS Coordinator, and Director of Nursing, confirmed the laptop's absence. The facility's policy on abuse prohibition, which includes protection from misappropriation of property, was not effectively implemented in this case, as the laptop remained missing despite efforts to locate it. The facility did not document a report to law enforcement or conduct comprehensive staff and resident interviews to conclude the investigation.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of possible misappropriation of property to the State Survey Agency within the required 24-hour timeframe after staff became aware of the incident involving a resident's missing laptop. The resident, who was cognitively intact and required minimal assistance with activities of daily living, reported the missing laptop to the Housekeeping Supervisor around the middle to end of November. The Housekeeping Supervisor then reported the incident to the Administrator on the same day. However, the Administrator did not report the incident to the Department of Health and Senior Services (DHSS) until December 5th, which was beyond the required reporting timeframe. Interviews with various staff members, including the Business Office Manager, MDS Coordinator, and Certified Nursing Assistants, revealed that there was a general understanding among staff that misappropriation should be reported immediately to the Administrator and considered a crime. Despite this, there was confusion about whether the incident needed to be reported to law enforcement. The Administrator admitted to knowing about the missing laptop earlier but did not follow up on the situation, assuming it had been resolved when no further information was provided. The Administrator's failure to report the incident to law enforcement was based on advice from corporate staff, who indicated it was unnecessary since the laptop was only reported as missing. The Administrator did eventually report the incident to DHSS because it was documented on the resident's inventory sheet. However, the delay in reporting and the lack of notification to law enforcement constituted a failure to adhere to the facility's policy and regulatory requirements for reporting suspected misappropriation of resident property.
Failure to Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of misappropriation involving a resident's missing laptop. The resident, who was cognitively intact and required minimal assistance, reported the missing laptop to the housekeeping supervisor after moving rooms. Despite the report, the facility did not document a comprehensive investigation, including interviews with staff and residents or a report to law enforcement. The facility's policy mandates immediate and thorough investigations into allegations of misappropriation, including interviews with relevant parties and documentation of findings. However, the investigation was incomplete, lacking documentation of interviews with staff and residents, and no police report was filed. The resident expressed dissatisfaction with the facility's response, noting that staff did not assist in filing a police report and that there was no reimbursement for the missing laptop. Interviews with various staff members, including the housekeeping supervisor, Business Office Manager, and Director of Nursing, revealed inconsistencies in the investigation process. The Administrator acknowledged that interviews were conducted but not documented, and there were no cameras in the hallways to review. The investigation did not meet the facility's policy requirements, resulting in a deficiency in handling the misappropriation allegation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 146 citations issued within 25 miles in the last 12 months — including the 1 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Willard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ash Grove Healthcare Facility | 7 mi | ★★★★★ | 2 | 0 |
| Springfield Skilled Care Center | 8.3 mi | ★★★★★ | 7 | 0 |
| Brookhaven Nursing & Rehab | 8.3 mi | ★★★★★ | 4 | 0 |
| Wilson's Creek Nursing & Rehab | 8.4 mi | ★★★★★ | 4 | 0 |
| Maranatha Village, Inc | 8.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Willard Care Center.
100% money-back within 48 hours.
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.