Average — CMS composite of the measures below.
The next survey window likely opens 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 Care Nursing Home during CMS and state inspections, most recent first.
Unsanitary kitchen, food storage, and dining area conditions: Surveyors found heavy grime and debris on the dishwasher area, sinks, walls, ceiling diffuser, ice machine, gas range, can opener, tilt skillet, and walk-in refrigerator, along with an unlabeled, undated pie. Dry storage also had unlabeled or undated containers and canned foods without expiration dates. In the food service area, a cake with whipped dairy topping and gelatin dessert were observed at improper temperatures, and the dining area had an out-of-order ice dispenser plus damaged tables and wall surfaces.
The facility failed to timely close out resident trust fund accounts after death or discharge for multiple residents, leaving balances unresolved well beyond the 30-day requirement. It also failed to provide written notice when one resident’s account was within $200 of the SSI limit and later exceeded it, despite the BOM and Administrator stating that written notifications and final accountings were expected.
Failure to monitor antibiotic use and follow ordered therapy duration. The facility did not maintain an IPCP with antibiotic stewardship and surveillance documentation, with repeated gaps in infection and antibiotic tracking records. A resident with a UTI was ordered levofloxacin for five days, but the MAR showed the antibiotic continued beyond the ordered duration, and staff interviews confirmed the stop date was missed and the stewardship log lacked required details.
A resident with an indwelling catheter, UTI, BPH, and urinary retention had the catheter drainage bag observed hanging from the bed frame or wheelchair with the bottom of the bag resting on the floor. Staff stated the bag should be below the bladder, covered, and never touch the floor, and the facility policy required catheter tubing and drainage bags to be kept off the floor.
The facility failed to provide SNF ABN notices to two residents at least two days before discharge from skilled services, as required. This notice is essential for informing residents about potential non-coverage and financial liability. Interviews confirmed the expectation for timely issuance of these notices, which was not met.
The facility failed to provide timely written notifications to residents and/or their representatives regarding hospital transfers or discharges, affecting three residents. Interviews revealed missing transfer notices and a lack of discharge notice for a resident discharged home. The Administrator acknowledged the expectation for such notifications, but the facility lacked a policy for transfer/discharge notifications.
The facility failed to accurately code the MDS for several residents, resulting in discrepancies between medical records and MDS assessments. A resident on hospice care was not coded for a life expectancy of less than six months, another receiving chemotherapy was not coded for cancer, a resident using a seatbelt restraint was not documented as such, and a resident on anticoagulants was not coded for receiving them. Staff interviews confirmed the expectation for accurate MDS coding.
The facility failed to follow physician orders for two residents regarding blood sugar management. One resident did not have their capillary blood glucose levels checked as ordered, while another received insulin without physician consultation for a high blood sugar level. Staff interviews revealed confusion about the orders and failure to adhere to protocols.
A resident with obstructive uropathy and other conditions had a catheter inserted without a physician's order after pulling out the previous one. The facility's policy requires physician orders for catheter placement and care, but the LPN did not obtain them, and the NP on call was not contacted. The DON expected nurses to follow this protocol, leading to a deficiency.
A resident with multiple health conditions, including rheumatoid arthritis and a chronic ulcer, did not receive prescribed pain medications consistently, leading to unmanaged pain during wound care. Observations and interviews revealed that pain medication was often administered after procedures, contrary to physician orders. Staff interviews confirmed a lack of adherence to pain management protocols, despite expectations from the DON and Administrator.
The facility failed to identify and address PTSD in two residents, lacking documentation of trauma screenings and personalized care plans. Interviews revealed that residents were not asked about their PTSD or triggers, and staff were unclear about the process for integrating trauma findings into care plans.
The facility did not meet the requirement of twelve hours of annual in-service education for CNAs, affecting two CNAs. CNA D and CNA E each received only three hours and 30 minutes of training, contrary to the facility's policy. The Administrator and DON confirmed the expectation for CNAs to complete the required training hours.
Unsanitary kitchen, food storage, and dining area conditions
Penalty
Summary
Food was not stored, prepared, distributed, and served under sanitary conditions in the kitchen, dining area, and food storage areas. Survey observations found the commercial dishwasher exterior with flaky white grime and debris on the floor beneath, oily film and brown grime on the floor and plumbing pipes below the dishwashing area and three-compartment sinks, a dark grime build-up behind the dishwashing sink spray rinsing and disposal area, an open backsplash section with a black substance, dust and a brown substance on a ceiling diffuser, and the ice machine with white grime on the exterior and interior plastic surfaces and debris on the floor beneath. The gas range, commercial can opener, tilt skillet, and walk-in refrigerator also had oily film, food debris, grime build-up, and an unlabeled, undated chocolate pie in the refrigerator. The dry food storage area contained an undated, unlabeled covered container of oatmeal, a loosely covered undated container of sugar, and multiple cans of diced peaches and diced tomato paste without expiration dates. In the food service area, a cake with whipped dairy dessert topping was at 61 degrees Fahrenheit and gelatin fruit dessert was at 51 degrees Fahrenheit. The dining area also had an out-of-order ice dispenser, non-intact laminate on two dining tables, a non-intact wooden corner on another table, and a scraped wall surface. Staff interviews confirmed the disposal leaked and caused dark build-up on the back wall and floor, the dishwasher area had not been cleaned for months, food bins were not dated, the ice machine and can opener should have been clean, cold foods should have remained refrigerated longer, and the kitchen, ceiling, walls, vents, and dining area surfaces should have been kept in good repair.
Resident Trust Funds Not Timely Closed Out or Notified
Penalty
Summary
The facility failed to refund resident trust funds within 30 days after discharge or death for multiple residents. Seven residents who expired had balances remaining in their resident trust fund accounts that were not closed out in a timely manner, with delays ranging from 75 days to 439 days. Six residents who were discharged to home or to the hospital also did not receive a final accounting of personal funds within 30 days, with account balances remaining unresolved from 60 days to 436 days after discharge. The report identified remaining balances such as $447.41, $112.27, $948.21, $15.06, $3.70, $12.42, $14.00, $12.25, $263.79, $612.39, $619.77, and $2,791.43 in the resident trust fund ledger after the residents had left the facility. The facility also failed to ensure timely written notification to a resident and/or responsible party when the resident’s account was within $200.00 of the SSI limit or when it exceeded that limit. For one resident who remained in the facility and received Medicaid benefits, the trust transaction history showed the account balance at $6,061.03, then $6,618.12, and then $7,143.97, while the record contained no resident fund notifications showing that the resident or representative was informed when the account was within $200.00 of the SSI limit. The facility policy stated that staff were to follow Missouri and SSA guidelines for resident funds, close out accounts when residents left with no plans to return, and provide notices related to resident fund changes. During interviews, the Business Office Manager stated he or she was responsible for identifying when residents were close to needing a spend down and that notification letters should be sent to the resident or representative, although verbal notifications had been given. The Administrator stated that resident accounts were expected to remain below the limit and that written notifications should be sent when accounts were within $200.00 of the resource limit, but verbal notifications had been made. Both also stated that residents should receive a final accounting of personal funds and the balance within 30 days after discharge.
Failure to Monitor Antibiotic Use and Follow Ordered Therapy Duration
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program that included an antibiotic stewardship program with infection surveillance and antibiotic use protocols. The facility’s policies stated that the IPCP should include surveillance, data analysis, antibiotic stewardship, and antibiotic usage reviews, and that the antibiotic stewardship program was intended to monitor antibiotic use in residents. However, the infection surveillance log showed repeated months with missing documentation, including no recorded pathogens, lab findings, infection criteria, diagnostic test details, antibiotic end dates, time-outs, organism information, or whether antibiotics were effective. For Resident #73, the physician order sheet dated 12/30/25 showed levofloxacin 500 mg daily for a UTI with no stop date, while the hospital discharge summary showed levofloxacin 500 mg daily for five days with a dispense quantity of five. The MAR showed the antibiotic was administered on 12/31/25, 01/01/26, 01/02/26, 01/03/26, 01/04/26, 01/05/26, 01/06/26, and 01/07/26. Nursing notes documented that the resident completed levofloxacin on 01/04/26, then continued to receive it afterward, and the physician was not notified of the five-day order until 01/07/26. The record also showed that the facility’s antibiotic surveillance documentation for December 2025 listed Resident #73 with an antibiotic end date of 01/04/26 and a five-day therapy duration, but there was no documentation of a diagnostic test performed, antibiotic time-out, or whether signs and symptoms resolved. Staff interviews confirmed the discrepancy: the CMT stated the resident received an antibiotic that morning and seven tablets had been delivered from the pharmacy, the pharmacy employee said seven tablets were dispensed, the RN said the stop date was missed, the DON said the antibiotic should have had an end date and should have been given for five days, and the Administrator stated he expected the facility to follow antibiotic orders and complete antibiotic stewardship logs per policy.
Urinary Catheter Drainage Bag on Floor
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter drainage bag was maintained in the proper position for one resident. The resident had diagnoses of UTI, BPH, and urinary retention, and had orders for catheter drainage every shift, catheter care every shift, monthly catheter and drainage bag changes, and catheter anchor changes. The resident’s MDS showed use of an indwelling catheter and dependence for toileting hygiene, and the care plan identified the catheter and need for assistance with toileting. During multiple observations, the resident was seen in bed and in a wheelchair with the catheter drainage bag hanging from the bed frame or wheelchair crossbars, covered by a privacy bag with an open bottom, and the drainage bag resting on the floor. Staff interviews confirmed that catheter drainage bags should be kept below the bladder, hung on the side of the bed or under the wheelchair, covered, and never touch the floor. The facility policy also stated that catheter tubing and drainage bags should be kept off the floor.
Failure to Provide SNF ABN Notices
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents and/or their representatives in writing at least two calendar days before discharge from skilled services. This notice is crucial as it informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. The deficiency affected two residents out of three sampled, with no documentation showing that the residents or their representatives received the SNF ABN form at least two days before the skilled Medicare services ended. Resident #15 was discharged from skilled Medicare services on August 16, 2024, and remained in the facility without receiving the required SNF ABN. Similarly, Resident #56 was discharged on July 2, 2024, and also remained in the facility without receiving the notice. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the expectation was for residents discharging from skilled Medicare services to receive the SNF ABN form at least 48 hours in advance, which did not occur in these cases.
Failure to Provide Written Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding transfers or discharges to a hospital, as required by regulations. This deficiency was identified for three residents out of a sample of six, with a total facility census of 72. Specifically, Resident #15 was transferred to the hospital on two occasions, 04/27/24 and 05/13/24, without any documented written notification to the resident or their representative. Similarly, Resident #34 was transferred to the hospital on 09/03/24, and Resident #70 was transferred on 06/05/24 and discharged on 07/07/24, with no written notifications provided for these events. Interviews conducted during the investigation revealed that the Social Services Designee was unable to locate a transfer notice for Resident #70's hospital transfer on 06/05/24, and no discharge notice was sent when the resident was discharged home on 07/07/24. The facility's Administrator acknowledged the expectation that residents and/or their representatives should receive written transfer or discharge notices prior to hospital transfers and at the time of discharge. The facility also did not provide a policy for transfer/discharge notifications, further contributing to the deficiency.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies between the residents' medical records and their MDS assessments. Resident #22, diagnosed with Parkinson's disease, dementia, and heart failure, was inaccurately coded as not having a condition that may result in a life expectancy of less than six months, despite being on hospice care. Resident #42, with diagnoses of rectal cancer, heart failure, and morbid obesity, was not coded for cancer in the MDS, although the resident was receiving chemotherapy. Resident #52's MDS did not reflect the use of a seatbelt as a restraint, despite documentation and care plans indicating its use. Additionally, Resident #63, diagnosed with Alzheimer's disease, bipolar disorder, and high blood pressure, was not coded as receiving an anticoagulant, although there was an order for Xarelto. Interviews with facility staff, including the MDS Coordinator and the Administrator, confirmed that the MDS should accurately reflect the residents' current conditions, which was not the case in these instances.
Failure to Follow Physician Orders for Blood Sugar Management
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident #9, who has a history of PTSD, major depressive disorder, dementia, drug-induced diabetes, and a chronic ulcer, the facility did not consistently check capillary blood glucose (CBG) levels as ordered. The Physician Order Sheet required CBG checks three times a week, but the Treatment Administration Record showed missed checks on three occasions. Interviews revealed that while the resident had previously refused checks, there were no recent refusals, and staff were unclear about the specific schedule for these checks. For Resident #20, diagnosed with diabetes mellitus, the facility failed to follow the sliding scale insulin order. An LPN administered 8 units of Fiasp insulin for a blood sugar level of 501 without contacting the physician, as the sliding scale only provided instructions up to a blood sugar level of 400. The LPN and the Director of Nursing both acknowledged that the protocol required contacting the physician for blood sugar levels above 400, but this was not done, resulting in a deviation from the physician's orders.
Failure to Obtain Physician Orders for Catheter Care
Penalty
Summary
The facility failed to obtain physician orders for the placement and care of an indwelling catheter for a resident diagnosed with obstructive uropathy, epilepsy, altered mental status, and generalized anxiety disorder. The resident was admitted with a catheter, but there was no documented physician order for its placement or care in the Physician Order Sheet. The resident had previously pulled out the catheter, and a new one was inserted by an LPN without obtaining a physician's order, as confirmed by the Nurse Practitioner who was on call at the time. Observations and interviews revealed that catheter care was typically performed by CNAs, and the LPN involved did not recall contacting the physician for orders. The Director of Nursing stated that she would expect a nurse to call the physician for an order before placing a catheter or performing catheter care. This lack of adherence to the facility's policy and procedures for obtaining physician orders and documenting them in the medical record led to the deficiency.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #9, who was experiencing almost constant pain. The resident had multiple diagnoses, including PTSD, major depressive disorder, dementia, rheumatoid arthritis, and a non-pressure chronic ulcer on the right lower leg. The facility's policy on pain management required regular assessment and administration of pain medication as per physician orders. However, the resident's medical records showed missed doses of prescribed pain medications, including Oxycontin and hydrocodone-acetaminophen, on several occasions. Observations and interviews revealed that Resident #9 did not receive pain medication as ordered before wound dressing changes, leading to visible signs of pain during the procedure. The resident reported that pain medication was often administered after the dressing change or not at all, resulting in prolonged periods of unmanaged pain. The facility's policy required pain to be assessed and managed according to the resident's needs and physician orders, but this was not consistently followed. Interviews with staff, including a Certified Medication Technician and LPNs, indicated a lack of adherence to the physician's orders for pain management. The Director of Nursing and Administrator acknowledged the expectation for orders to be followed and for residents to be appropriately medicated for pain. Despite these expectations, the facility did not ensure that Resident #9 received timely and effective pain management, as evidenced by the missed medication doses and the resident's reports of ongoing pain.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two residents diagnosed with post-traumatic stress disorder (PTSD). Both residents, one with additional diagnoses of major depressive disorder (MDD) and paranoid schizophrenia, and the other with MDD, dementia, and other health issues, did not have documentation of a trauma questionnaire or screening to identify PTSD and triggers. The care plans for these residents did not address PTSD, personalized triggers, or interventions related to their conditions. Interviews with the residents revealed that they had not been asked about their PTSD or triggers, and they felt that their traumatic experiences were not acknowledged or addressed by the facility. Interviews with facility staff, including the Social Services Director, LPN, CNA, and MDS Coordinator, indicated a lack of clarity and communication regarding the trauma screening process and the integration of findings into the residents' care plans. The staff mentioned that trauma questionnaires were conducted upon admission, but there was confusion about where the information was directed and how it was used to update care plans. The MDS Coordinator confirmed that care plans should address PTSD, trauma, and triggers, but this was not reflected in the care plans of the two residents in question.
Deficiency in CNA In-Service Education Hours
Penalty
Summary
The facility failed to provide the required twelve hours of annual in-service education for Certified Nurse Assistants (CNAs), affecting two sampled CNAs. CNA D, hired on 07/28/21, received only three hours and 30 minutes of training from July 2023 through July 2024, falling short of the mandated twelve hours. Similarly, CNA E, hired on 04/12/13, also received only three hours and 30 minutes of training for the period from April 2023 through April 2024. The facility's policy, revised in August 2010, mandates that each nursing assistant must attend a minimum of twelve hours of continuing education annually. Interviews with the Administrator and the Director of Nursing (DON) confirmed the expectation that CNAs should complete at least twelve hours of in-service education each year.
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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 Willow Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kabul Nursing Homes Inc | 11.4 mi | ★★★★★ | 7 | 0 |
| Mountain View Healthcare | 16 mi | ★★★★★ | 0 | 0 |
| Brooke Haven Healthcare | 17.8 mi | ★★★★★ | 9 | 0 |
| Autumn Oaks Caring Center | 18.2 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare, West Plains | 18.7 mi | ★★★★★ | 0 | 0 |
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