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 Embassy Of Willard during CMS and state inspections, most recent first.
Failure to administer ordered medications: A resident with pancreatic cancer, schizophrenia, and DM had hospice admission orders for multiple meds, including insulin, cardiac meds, thyroid replacement, antipsychotics, and an anticoagulant, but the physician orders were not transcribed and the MAR showed no evidence the resident received them for several days after admission. The DON confirmed the meds were not given, and SS and the hospice RN stated the resident came with a med list and should have received the ordered meds on admission.
A resident with pancreatic cancer, schizophrenia, and type II DM had Hospice insulin orders for glargine and lispro, but the facility’s physician orders did not include the insulin and the MAR showed no insulin administration or FSBS monitoring over several days. The DON stated the admission nurse did not transcribe the meds because of confusion over discontinued Hospice orders, and Hospice RN confirmed the resident should have received the ordered insulin.
A resident with significant mobility and cognitive impairments, who required full staff assistance and used a wheelchair, was not properly secured with a seat belt during transport on the facility bus. The transport driver, lacking adequate training, positioned the resident incorrectly and did not use the lap belt due to the wheelchair's tilt. During the trip, a wheelchair component broke, causing the resident to fall to the floor and sustain a subdural hematoma and subarachnoid hemorrhage, leading to ICU admission.
The facility failed to serve pureed dinner rolls or an appropriate substitution to residents on pureed diets, despite these items being available and listed on the lunch meal spreadsheet. This affected six residents and was confirmed by an interview with the cook.
The facility failed to maintain clean linens for a resident with psoriasis, despite the resident's requests and visible stains on the sheets and pillowcase. The resident's bedding was not changed as per the facility's policy, even when obviously soiled.
A resident with severe cognitive impairment and incontinence was found heavily soiled with urine and stool, indicating a lapse in the required two-hour checks and repositioning. Staff interviews confirmed the resident's dependency on frequent incontinence checks, which were not adequately performed.
The facility failed to ensure medications were administered properly and not left at the bedside. A resident with multiple diagnoses was observed with a medication cup containing eight pills in their room. Staff interviews confirmed that medications were left for the resident to self-administer, contrary to facility policy requiring nurses to observe medication consumption.
The facility failed to ensure staff used appropriate hand hygiene during meal services, affecting three residents. Observations revealed that an STNA did not perform hand hygiene between resident contacts, contrary to the facility's policy. This lapse was confirmed through staff interviews and direct observation.
The facility failed to ensure staff wore PPE when providing care to a resident in enhanced barrier precautions (EBP). Despite training and clear signage, staff members were observed not wearing PPE while assisting with the resident's transfer, violating the facility's policy.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to ensure medications were administered as physician ordered for a resident with malignant neoplasm of the pancreas, paranoid schizophrenia, and Type II diabetes mellitus. The resident was admitted with impaired cognition, evidenced by a BIMS score of 06, and required substantial assistance with ADLs. Hospice admission orders listed multiple medications, including Cardizem, insulin glargine, insulin lispro, levothyroxine, lisinopril, Latuda, Prilosec, pantoprazole, risperidone, and rivaroxaban, but the physician orders for February 2026 did not include these medications. The MAR showed no evidence that the resident received Cardizem, insulin glargine, insulin lispro, levothyroxine, lisinopril, Latuda, Prilosec, pantoprazole, risperidone, or rivaroxaban for several days after admission. The DON stated the medications were not transcribed because there was confusion over discontinued hospice orders, and confirmed the resident did not receive any physician-ordered medications during that period. Social Services and the hospice RN stated the resident arrived with a medication list from the oncologist and that the ordered medications should have been received on the day of admission.
Failure to Transcribe and Administer Ordered Insulin
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. Resident #54 was admitted with diagnoses including malignant neoplasm of the pancreas, paranoid schizophrenia, and type II diabetes mellitus, and the MDS showed impaired cognition with a BIMS score of 06. Hospice admission notes documented orders for insulin glargine 40 units twice daily and insulin lispro on a sliding scale, but the physician orders for February 2026 did not include either insulin order. The MAR showed no evidence the resident received insulin glargine on 02/27/26, 02/28/26, 03/01/26, or 03/02/26, and no evidence that insulin lispro was administered or that FSBS were obtained to determine whether sliding scale insulin was needed during that same period. The DON stated the admission nurse did not transcribe the medications because of confusion over discontinued Hospice orders and verified the resident did not receive insulin or have FSBS monitoring from 02/27/26 through 03/03/26. Hospice RN #219 stated the insulin orders were based on the oncologist’s medication list and confirmed the resident should have received insulin as ordered.
Failure to Properly Secure Wheelchair-Bound Resident During Transport Results in Serious Injury
Penalty
Summary
A facility failed to ensure that a resident, who was dependent on staff for all aspects of care and utilized a wheelchair for mobility, was safely secured with a seat belt and properly positioned during transport on the facility bus. The resident had significant medical conditions, including left-sided hemiplegia and hemiparesis following a stroke, dysphagia, dysarthria, diabetes with polyneuropathy, generalized muscle weakness, and was on anticoagulation therapy with aspirin and Plavix. The resident was unable to ambulate or stand independently and required assistance for all activities of daily living. On the day of the incident, the transportation driver loaded the resident into a tilt-in-space wheelchair and positioned her facing the passenger side of the bus, tilted back for comfort. The driver did not secure the resident with a lap belt, stating that the seat belt was obstructed by the wheelchair's position and that the resident's upper body would not move. The wheelchair was secured to the bus using four-point hooks, but the resident herself was not restrained with the seat belt. During transport, a bolt on the wheelchair broke, causing the left arm of the wheelchair to bend and the resident to fall out of the chair onto the floor of the bus. The incident was unwitnessed, and the driver continued to drive to a nearby hospital after discovering the resident on the floor. Upon evaluation at the hospital, the resident was found to have sustained a subdural hematoma and subarachnoid hemorrhage, requiring admission to the intensive care unit. The investigation revealed that the driver had limited training and had not previously driven a transport bus, and that the resident was not secured according to the facility's bus safety manual and wheelchair restraint guidelines.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure the menu was followed for residents receiving pureed diets, affecting six residents who were prescribed such diets. On the specified date, the lunch meal spreadsheet indicated that pureed dinner rolls should be included for these residents. However, during the tray line observation, it was noted that the pureed dinner rolls or an appropriate substitution were not served to the residents receiving pureed meals. This was confirmed by an interview with the cook, who acknowledged that the pureed dinner rolls were available but not served. The facility's policy on the accuracy and quality of tray line service, which mandates that all meals be checked for accuracy and that individuals receive the appropriate portions as outlined on the menu, was not adhered to.
Failure to Maintain Clean Linens for Resident
Penalty
Summary
The facility failed to ensure that Resident #39's sheets were maintained in a clean condition. Resident #39, who has a diagnosis of psoriasis and is independent in bed mobility and transfers, reported that his sheets were stained along the edge of the mattress near the head of his bed, and his pillowcase had several spots that appeared to be dried blood. Despite requesting a change of sheets since his previous shower, the linens remained unchanged. Observations confirmed the stained sheets and pillowcase on multiple occasions over several days. Interviews with Resident #39 and STNA #370 revealed that the resident's bedding was typically changed on shower days, but should also be changed when obviously soiled. Resident #39 refused his scheduled shower on one occasion, but still expected his bedding to be changed due to its soiled condition. The facility's policy on maintaining a safe and homelike environment, which includes providing clean bed and bath linens, was not adhered to in this instance.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was incontinent and dependent on staff for toileting. Resident #30, who had severe cognitive impairment and was always incontinent of bowel and bladder, was observed to be soiled with urine and stool. The resident was found in a reclining geriatric chair with urine soaking through the adult incontinence brief, shorts, lift sling, and onto the seat cushion. The resident's shirt was also wet with urine. The staff last checked the resident for incontinence and repositioning at 7:15 A.M., and the soiling was discovered at 10:37 A.M., indicating a lapse in the required two-hour checks and repositioning. Interviews with the staff, including the State tested Nurse Aide (STNA) and the Registered Nurse (RN), confirmed that Resident #30 required frequent incontinence checks and repositioning due to their inability to inform staff of their needs. The Director of Nursing (DON) verified that no interventions were implemented to determine the resident's bowel or bladder habits, including the frequency of incontinence checks to prevent heavy soiling. The facility's incontinence policy stated that residents who are incontinent of bladder or bowel would receive appropriate treatment to prevent infections and restore continence to the extent possible, which was not adhered to in this case.
Failure to Properly Administer Medications
Penalty
Summary
The facility failed to ensure medications were administered properly and were not left at the resident's bedside. This deficiency was identified during a review of Resident #40's medical record, observation, and interviews with the resident and staff. Resident #40, who has multiple diagnoses including chronic gout, type II diabetes mellitus, and hypertension, was observed with a medication cup containing eight unidentified pills on a table in their room. The resident reported that staff routinely left medications in the room because they trusted the resident to take them, and it took the resident approximately 15 minutes to consume all their morning medications. An interview with LPN #807 confirmed that they had left Resident #40's morning medications in the room without observing the resident consume them. Another LPN, #801, stated that no residents in the building were allowed to self-administer medications and that nurses were required to observe all residents swallow their medications. The Director of Nursing (DON) verified that Resident #40 should have been observed while taking their medications. The facility's policy on medication administration, dated 08/22/22, mandates that medications are to be administered by licensed nurses or authorized staff and that resident consumption of medication must be observed.
Failure to Perform Hand Hygiene During Meal Services
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene during meal services, affecting three residents on the 400-hall. Observations revealed that a State tested Nurse Aide (STNA) did not perform hand hygiene after adjusting a resident's socks and before handling another resident's breakfast tray. The STNA confirmed that she only performed hand hygiene before passing the first tray and after finishing all trays, not between resident contacts as required by the facility's hand hygiene policy. Further observations showed that the same STNA continued to pass meal trays to other residents without performing hand hygiene between contacts. The facility's hand hygiene policy, which was reviewed, indicated that hand hygiene should be performed between resident contacts. This failure to adhere to the policy was confirmed through staff interviews and direct observation, highlighting a lapse in maintaining professional standards for food service and resident care.
Failure to Adhere to PPE Protocols for Resident in Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff wore personal protective equipment (PPE) when providing care to residents in enhanced barrier precautions (EBP). This deficiency was observed in the case of Resident #26, who had a chronic wound and required EBP as per physician orders. Despite a sign posted on the resident's door and a plastic cart with gowns and gloves available outside the room, staff members were observed not wearing PPE while assisting with the resident's transfer. Specifically, STNA #408 and STNA #301 did not don PPE, although STNA #404 did comply with the requirement. Interviews with the involved staff confirmed the failure to adhere to the PPE protocol. STNA #404 acknowledged that PPE was required for transferring residents in EBP, and the Regional Director of Clinical Services confirmed that all staff had been educated on EBP and PPE usage in March 2024. A review of the staff in-service sign-in sheet showed that both STNA #301 and STNA #408 had attended the training. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, clearly stated that gown and gloves should be used during high-contact resident care activities, including transfers.
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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 Willard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows At Willard The | 1.9 mi | ★★★★★ | 10 | 0 |
| Crestwood Care Center | 11.8 mi | ★★★★★ | 0 | 0 |
| Shelby Pointe | 12.8 mi | ★★★★★ | 0 | 0 |
| Norwalk Memorial Home | 13.7 mi | ★★★★★ | 1 | 0 |
| Twilight Gardens Nursing And Rehabilitation | 13.8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.