Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Food was observed exposed to contamination in the kitchen and walk-in cooler, including fans and a ceiling vent with dirt and dust buildup, a box of baking soda with black spots on the outside, and hall trays stored under a dusty vent while being prepared for service. Staff interviews showed unclear responsibility for cleaning fans and vents and for maintaining cooler items. In the dish room, trays and plastic ware were observed stacked wet and dirty with leftover food particles, despite policy requiring items to be checked for cleanliness and air dried before stacking.
Failure to Complete Required Neurological Assessments After Falls: Nursing staff did not complete or fully document required neuro checks after falls with possible head injury for multiple residents. One resident with vascular dementia and a head bump and laceration had no follow-up progress note or documented neuro checks after the fall, and the neuro flow sheet lacked documentation of wounds, vomiting, and headache. Two other residents with dementia, Parkinson’s disease, and repeated falls had initial neuro checks after falls with facial or head bruising, but the record did not show the required follow-up assessments.
Food Served at Unsafe Temperatures: A Dietary staff member portioned pureed hot dogs and spinach ahead of time, placed them directly on the steam table, and later served four puree meals without reheating them. The meals were observed at 114 degrees F and 110 degrees F, below the facility’s stated hot food holding minimums, and the DM, RD, and Administrator all stated those temperatures were not appropriate for serve out.
TB screening was not completed as required for several new staff members. The MD and MR did not receive TB testing until after they had already had contact with residents, one HK did not have a documented second-step TB test, and two other staff members had delayed second-step testing. The DON and Administrator stated staff should have TB screening or a negative TB test before working with residents.
A resident receiving Medicare Part A skilled services did not receive the required SNFABN when coverage ended, even though a NOMNC was issued. Survey review found the facility lacked a policy for the SNFABN, and the BOM and Administrator acknowledged the required notice was missed before therapy discharge.
Urine Odor Persisted in Resident Room: A resident with bladder incontinence and multiple medical diagnoses had a room that repeatedly smelled strongly of urine during several observations. The resident’s urinal was left on a dresser with urine, residue, and an extremely strong odor, and staff interviews showed inconsistent practices for emptying and rinsing urinals despite acknowledging that urine odor in a resident room should be identified and corrected.
Inconsistent Code Status Documentation: The facility failed to keep code status consistent across records for two residents. Both residents had DNR documented in the electronic record, current POS, and care plan, but the face sheet binder at the nurses' station listed them as full code, and staff gave inconsistent answers about where to find code status. The DON stated there was no system in place for code status audits, while the Administrator said audits were done bi-monthly.
Failure to identify and monitor pressure ulcers: A resident with hemiplegia, incontinence, contractures, and impaired mobility had repeated weekly skin checks that did not fully assess or document a heel wound and toe wound. Staff entered a treatment order for the left ankle/heel area but did not consistently document wound care or progress notes, and the DON was not aware the wounds were pressure ulcers until the wound NP first evaluated them and found a stage 3 heel ulcer and an unstageable toe ulcer.
Catheter Tubing Dragging on Floor: A resident with an indwelling urinary catheter, moderate cognitive impairment, and a history of frequent UTIs was observed multiple times in a wheelchair with the catheter tubing touching and dragging on the floor in the dining room. The care plan directed staff not to let any part of the drainage system touch the floor, but staff interviews showed some CNAs did not know how to position the bag high enough under the wheelchair to prevent the tubing from dragging.
A resident with paraplegia and a colostomy did not have a physician order for colostomy wafer and bag changes. The chart included an order to assess the stoma each shift and document output and stoma color, but staff reported changing the wafer and bag based on leakage or about weekly, and the DON stated an order should have been in place for changes every four days and PRN.
Failure to Notify MD and Care Plan Suicidal Comments: A resident on hospice with terminal cancer, depression, anxiety, and severe pain repeatedly made suicidal statements and gestures, including comments about wrapping a call light cord around his/her neck and wanting to die. Staff sometimes placed the resident on 15-minute checks and contacted hospice or social services, but nurse notes did not document notifying the MD of the suicidal comments, and the care plan did not include specific interventions for suicide prevention.
A resident with overactive bladder, paraplegia, and both a Foley and suprapubic catheter did not receive an ordered bladder spasm medication as prescribed because staff repeatedly documented it as unavailable or discontinued. The MAR showed multiple missed doses over several weeks, while the chart lacked documentation of physician notification, pharmacy follow-up, or a clear discontinuation order. Staff interviews reflected confusion about whether the medication had been stopped, and the resident reported ongoing urine leakage related to bladder spasms.
Failure to inspect loose bed rails: A resident with stroke-related hemiplegia had quarter upper bed rails ordered for positioning, but the right rail was repeatedly observed to be extremely loose and nearly at a 45-degree angle. The chart lacked documentation of regular safety checks, and staff interviews showed the loose rail should have been noticed and reported to nursing and maintenance, while the Maintenance Director said the condition was a safety issue.
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.
Food Storage and Dish Sanitation Deficiencies
Penalty
Summary
Food was not protected from contamination in the kitchen and walk-in cooler. During observations, fans in the cooler had substantial dirt and dust buildup, one ceiling vent near a dish storage rack and entry door had visible dirt and dust, and a box of baking soda in the cooler had black spots all over the outside of the container. The hall trays were stored in a cart under the vent while they were being prepared for service. Staff interviews showed differing understanding of who was responsible for cleaning the fans and vents and for maintaining items stored in the cooler in appropriate condition. The dish room was also observed to have sanitation issues. Metal trays of multiple sizes were stacked wet and dirty with leftover food particles inside, and small plastic cups ready for use were stacked wet. On another observation, metal trays ready for use were stacked wet and dirty with leftover food particles, and plastic serving bowls were stacked with leftover food particles and wet. The facility policy required items to be checked for cleanliness at the clean end of the dish machine, re-washed if not clean, and air dried with no moisture on stacked items. Interviews with dietary staff, the dietary manager, the registered dietician, the maintenance director, and the administrator confirmed that dishes should be air dried and inspected for cleanliness before stacking, and that fans and vents should not have dirt and dust on them. The report also noted that the facility did not provide a signed day shift checklist showing completion of the required tasks.
Failure to Complete Required Neurological Assessments After Falls
Penalty
Summary
The facility failed to ensure residents received care and treatment in accordance with professional standards of practice when nursing staff did not provide appropriate neurological assessments after falls with potential head injury for three residents. The facility policy required observation and documentation after falls, including monitoring for headache, altered consciousness, unequal pupils, vomiting, bleeding, and other neurological changes, along with frequent monitoring until stable and notification of the physician for condition changes. Resident #31 had a history of vascular dementia, unsteady gait, fatigue, and falls. After a fall in the dining room, the resident hit the back of the head and had a 2.5 cm by 2.5 cm bump on the top back of the head and a 2.0 cm laceration to the left elbow. The nurse notified the physician and family, but the next day there was no progress note or follow-up documentation of the resident’s condition after the head injury and no documented neurological checks. The neurological assessment flow sheet showed some entries for consciousness, pupil response, motor function, and vital signs at several times, but the observations section for wounds, vomiting, and headache was not documented. Resident #5 had diagnoses including dementia, heart disease, anxiety, depression, and repeated falls, with moderate cognitive impairment and wheelchair use. The resident had multiple falls in which staff documented a neurological check at the time of the fall, including falls with a scraped and bruised eyebrow area, an unwitnessed fall with a bruise on the left temple, a fall with a knot on the left side of the forehead, and an unwitnessed fall with no injuries noted. In each of these events, the record did not show additional follow-up neurological checks after the initial assessment. Resident #15 had Parkinson’s disease, chronic kidney disease, osteoporosis, a history of fractures, and a history of falls, with severe cognitive impairment and dependence on staff for transfers and toileting. After a fall with a scraped forehead and another unwitnessed fall with a raised and bruised area around one eye near the nose, staff completed a neurological check at the time of the fall, but the record did not show additional follow-up neurological checks.
Food Served at Unsafe Temperatures
Penalty
Summary
The facility failed to ensure food was served at a safe and appetizing temperature when four pureed meals were held on the steam table at temperatures below the facility’s stated minimums before being served. Facility policy required the Dietary Manager or designee to verify proper serving temperatures before trays were assembled, keep hot foods at no less than 140 degrees Fahrenheit during meal service, and not portion out pureed food ahead of time. Despite this, a Dietary staff member began pureeing hot dogs and spinach for four puree meals, placed the finished pureed foods into plastic serving bowls covered with plastic wrap, and set them directly on the steam table. When observed later, the pureed hot dogs measured 114 degrees Fahrenheit and the pureed spinach measured 110 degrees Fahrenheit on the steam table. The staff member then served two puree meals to the memory care unit and the remaining two puree meals to the dining room without reheating them. During interviews, the staff member stated foods on the steam table should be held at a minimum of 140 degrees Fahrenheit and acknowledged the meals should not have been served at 114 and 110 degrees Fahrenheit. The DM, RD, and Administrator also stated that these temperatures were not appropriate for serve out.
TB Screening Not Completed for New Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when it did not have processes in place to ensure all new staff were screened for tuberculosis before employment. Survey review found that the Maintenance Director had a hire date of 07/11/25, but the first step of the TB skin test was not administered until 12/02/25, after the employee had already had contact with residents. The Medical Records employee had a hire date of 09/23/24, but the first TB skin test was not administered until 06/26/25, also after contact with residents. The facility also failed to fully complete TB testing for other staff. Housekeeper C was hired on 01/29/25, received the first TB skin test on the hire date, but the facility did not complete and document a second-step TB test. CNA A was hired on 12/15/25, received the first TB skin test on the hire date, and the second TB skin test was given about four weeks later. RN B was hired on 02/17/25, received the first TB skin test on 02/14/25, and the second TB skin test was administered about six weeks later. During interview, the DON and Administrator stated that employees should have a TB test or screening, or a negative TB test or other screening such as an x-ray, before working with residents.
Failure to Issue Required Medicare Coverage Notice
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) at the initiation, reduction, or termination of Medicare Part A benefits for one sampled resident who remained in the facility after Medicare Part A services ended. Survey review showed that the resident’s Medicare Part A skilled services began on 12/31/25, the last covered day was listed as 02/09/25, and a Notice of Medicare Non-Coverage (NOMNC, CMS-10123) was issued in writing. However, the facility did not provide the resident or legal representative with the SNFABN or an alternative denial letter. The report also states the facility did not provide a policy related to giving residents or resident representatives the SNFABN form CMS-10055. During interviews, the Business Office Manager said she missed sending the required notification and that it should have been given prior to discharge from therapy. The Administrator said she did not know all required forms were not sent to residents when Medicare Part A services were being terminated and stated the notification should have been given prior to discharge from therapy.
Urine Odor Persisted in Resident Room
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment when Resident #19’s room repeatedly had a strong odor of urine. The resident was admitted with diagnoses including a fractured left femur, vascular dementia, heart disease, stroke, and obsessive compulsive disorder. The admission MDS showed the resident was cognitively intact, required substantial assistance with toileting, and was frequently incontinent of bladder. The care plan directed staff to provide toileting assistance, incontinence care after each incontinent episode, and to use a chux and brief while the resident was in bed. During multiple observations, the resident was seen lying in bed eating meals while the room had a very strong odor of urine. On one observation, the resident’s urinal sat on the dresser next to the bed with a small amount of urine inside, residue-like substance on the inside, and an extremely strong odor of urine that caused the room to smell strongly of urine. On another observation, the room still had a strong urine odor and the urinal continued to have an extremely strong odor up close. Staff interviews showed differing practices for emptying and rinsing urinals, and staff acknowledged that urine odor in a resident room should be investigated and corrected. The DON and Administrator also stated that staff should empty urinals every two hours or as needed and replace urinals with residue and odor.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure a system was in place that clearly and consistently represented each resident's code status in the medical record. During review, two residents had DNR status documented in the electronic face sheet, current physician orders, and care plans, but the Resident Face Sheet binder at the nurses' station showed full code for both residents. The facility policy stated that information about whether a resident had executed an advance directive should be displayed prominently in the medical record under the advance directive tab. Resident #1 had an admission date, a DNR code status on the electronic face sheet, a current physician order for DNR, and a care plan revised to reflect DNR, but the face sheet in the binder showed full code with an OHDNR placed behind it. Resident #26 had the same pattern: DNR was documented in the electronic face sheet, care plan, and current physician order, while the face sheet in the binder showed full code with the OHDNR behind it. Staff interviews showed inconsistent understanding of where code status was located, and the DON stated there was no system in place for audits for code status, while the Administrator stated the DON and records staff conducted bi-monthly audits.
Failure to Identify and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received care according to standards of practice when staff did not properly identify, assess, and monitor the resident’s skin condition. The resident had a history of stroke with hemiplegia, moderate cognitive impairment, impaired mobility, incontinence, contractures, and was at risk for pressure ulcers. The quarterly MDS indicated the resident had unhealed pressure ulcers and used pressure-reducing devices for the bed and chair, but weekly skin assessments repeatedly documented only vague findings such as edema, thin/frail skin, and an ulcer at the Foley catheter site, without identifying or fully assessing the resident’s heel and toe wounds. The record showed that a treatment order for the left ankle was entered and carried out inconsistently, and the weekly skin assessments did not include complete wound assessments of the left ankle/heel wound. Progress notes also lacked entries describing the wound condition over multiple dates. One treatment was not initialed on the MAR, and the resident’s skin assessments continued to describe the wound only in general terms, with no documented wound measurements or detailed assessment until the wound nurse practitioner first evaluated the resident. During observation, the resident stated the heels hurt and that padded heel protectors helped relieve the pain, and the resident was wearing socks without heel protectors at that time. On the day the wound nurse practitioner first saw the resident, the left lateral heel wound was measured at 1.8 cm by 1.0 cm by 0.20 cm and identified as a stage 3 pressure ulcer. The resident also had a dark brown scabbed area on the right great toe that was identified as an unstageable pressure ulcer. The wound nurse practitioner stated this was the first time the facility had asked for the resident to be seen and assessed for the wounds, and the RN stated that prior to that day, nurses had not documented wound assessments on the left outer heel or right great toe and had not recognized the wounds as pressure ulcers. The DON stated the nurses were responsible for weekly skin assessments and should notify the DON immediately if a pressure ulcer was identified, but the DON was not aware of the resident’s pressure ulcers until the day before the wound nurse practitioner’s first evaluation.
Catheter Tubing Allowed to Drag on the Floor
Penalty
Summary
The facility failed to provide services to prevent possible urinary tract infections when staff allowed a resident’s urinary catheter tubing to touch the floor. Resident #2 had an indwelling urinary catheter related to benign prostatic hyperplasia with lower urinary tract symptoms and a history of frequent UTIs. The resident’s quarterly MDS showed moderate cognitive impairment and dependence on staff for toileting hygiene, lower body dressing, shoes, personal hygiene, transfers, and bed mobility. The care plan, updated 03/16/26, directed staff not to allow the catheter tubing or any part of the drainage system to touch the floor, to avoid obstruction in drainage, and to keep the drainage bag below bladder level. Observations showed the resident seated in a wheelchair in the dining room with the catheter drainage bag in a dignity bag under the wheelchair while the tubing lay on the dining room floor. This was observed again the next morning while the resident ate breakfast, with the tubing on the floor and containing dark yellow urine. On another observation, a CNA propelled the resident from the room to the dining room and the catheter tubing dragged on the floor under the wheelchair. Staff interviews confirmed that some staff did not know to position the bag high enough under the wheelchair to prevent the tubing from dragging, and the DON and Administrator stated the tubing should not drag the floor and that allowing it to do so posed an infection risk.
Missing physician order for colostomy wafer and bag changes
Penalty
Summary
The facility failed to ensure that Resident #6 had physician orders for colostomy wafer and bag changes. Resident #6 was admitted with diagnoses including paraplegia, anxiety, and depression, and the quarterly MDS showed the resident was cognitively intact, dependent on staff for toileting hygiene and lower body dressing, and had a colostomy. The care plan identified the resident as at risk for constipation related to the colostomy and decreased mobility, and directed staff to provide colostomy care each shift and as needed, including changing the bag as needed. The physician orders in April 2026 included an order to assess the stoma every shift and document output color, consistency, and stoma color, but there was no order for changing the colostomy wafer or bag. During observation, the resident stated staff changed the colostomy wafer and bag when it leaked. RN B stated he/she believed the wafer and bag were changed about once per week and more often if leaking, but could not find an order for the change frequency. RN F stated he/she was not aware a physician order was needed for wafer and bag changes and only changed them if loose or leaking. The DON stated nursing staff should have obtained an order for colostomy wafer and bag changes every four days and as needed, and the Administrator stated nurses should obtain a physician order for changing a resident's colostomy wafer and bag.
Failure to Notify Physician and Care Plan Suicidal Comments
Penalty
Summary
The facility failed to ensure appropriate mental health services and physician notification for a resident on hospice with rectal cancer, liver cancer, adjustment disorder, generalized anxiety disorder, depression, chronic fatigue, and weakness, after the resident made repeated suicidal comments and gestures. The resident was documented as making morbid jokes, asking staff to bring a gun, wrapping a call light cord around his/her neck, and later stating, "If I was strong enough, I would wrap the call light cord around my neck" and "I just want to die." Staff placed the resident on 15-minute checks at times and documented that the resident denied suicidal thoughts or said he/she was joking, but the nurse notes did not document notification of the resident's physician for these comments. The resident's record showed ongoing distress related to terminal illness and pain. Social services documented that the resident's depression stemmed from the medical condition and severe tumor-related pain. The resident's MDS showed moderate cognitive impairment, feeling down, depressed, or hopeless, and hallucinations. On another occasion, the resident made multiple comments about wanting to die and requested to speak to someone; hospice and social work were contacted, and a psychologist referral was later obtained. The resident also told the LCSW that pain, loss of bowel control, and loss of independence were the primary drivers of distress. Although the resident's care plan addressed anxiety, antipsychotic use, mood symptoms, and monitoring behaviors, it did not specifically address the resident's suicidal comments or include staff interventions specific to suicide prevention. During interviews, staff stated the resident's comments were viewed as joking or as a way of processing terminal cancer, and one nurse said he/she did not think about notifying the physician. The DON and Administrator later stated that when the resident made suicidal comments, staff should have ensured immediate safety, notified the physician, documented the notification and orders, and care planned the suicidal comments with specific interventions.
Ordered bladder spasm medication not available or administered
Penalty
Summary
The facility failed to ensure a physician-ordered bladder spasm medication was available and administered for one resident with overactive bladder, neuromuscular dysfunction of the bladder, paraplegia, and cauda equina syndrome. The resident’s orders included tolterodine 2 mg by mouth twice daily, but the medication was repeatedly documented as not administered because it was unavailable, not in the stat safe, not in the E-kit, or marked discontinued on the MAR. The record showed missed doses across March and April 2026, with no documentation in the progress notes of an order to discontinue the medication, physician notification of the missed doses, or pharmacy notification and follow-up regarding the missing medication. The resident’s assessments and care plans documented an indwelling urinary catheter and a suprapubic catheter, with staff directed to manage catheter care, assess drainage each shift, observe for leakage, and report complications. On 03/27/26, nursing documented that the catheter was not flushing well, sediment was noted in the tubing, and the resident stated, “Maybe that is why I have been leaking a lot.” The nurse changed the catheter and noted urine and a moderate amount of sediment. Later, during observation and interview, the resident was noted to have both a Foley catheter and a suprapubic catheter and stated that the catheters leaked urine at times due to bladder spasms. Interviews with nursing and medication staff showed confusion about the medication’s status and the process for obtaining it. One RN stated the resident had bladder spasms, urine leakage, and that the physician had increased the bladder spasm medication, but the RN was not aware the medication had not been administered as ordered. A CMT stated he or she thought the physician had discontinued the medication, while another CMT said staff were aware the resident did not have a supply of tolterodine. The DON and Administrator described that staff should notify nursing and pharmacy when a medication was unavailable, but the resident’s record did not show that the ordered medication was consistently obtained or administered as prescribed.
Failure to Inspect Loose Bed Rails
Penalty
Summary
The facility failed to complete regular inspections of bed frames and side rails for entrapment risk for one resident whose side rails were loose. Resident #51 was admitted with diagnoses including stroke, hemiplegia, type 2 diabetes mellitus, depression, mixed anxiety disorders, insomnia, and contracture of the left hand. The resident had a physician order for quarter upper bed rails for positioning, and the care plan identified the need for a half rail related to left-sided hemiplegia from stroke. The resident's bed rail and assessment consent showed the facility completed an assessment with measurements, clinical assessment, alternative attempts, and risks and benefits, but the record did not provide documentation of regular safety checks for the bed rails. During observations on 04/07/26, 04/08/26, and 04/09/26, the resident was in bed with quarter-size bilateral bed rails raised, and the right bed rail was repeatedly observed to be extremely loose, able to move up and down and side to side liberally, with the top nearly at a 45-degree angle. Staff interviews showed CNA D and CNA E said loose bed rails were unsafe and should be reported to the nurse and maintenance, and RN F said loose rails should be documented in the maintenance book. The Maintenance Director stated he conducted weekly safety checks and said the rail should not have been that loose and was a safety issue, while the DON and Administrator stated staff were responsible for noticing loose rails and notifying maintenance, but no concerns had been written in the maintenance log for this resident's bed rails.
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.
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What surveyors actually found near you
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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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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 | ★★★★★ | 13 | 0 |
| Brookhaven Nursing & Rehab | 8.3 mi | ★★★★★ | 1 | 0 |
| Wilson's Creek Nursing & Rehab | 8.4 mi | ★★★★★ | 0 | 0 |
| Maranatha Village, Inc | 8.9 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 August 2026) and official state health department websites.