Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Willows At Willard The during CMS and state inspections, most recent first.
Lack of Functional Communication Support: A resident with Alzheimer's disease, depression, and vascular dementia had severe cognitive impairment, unclear speech, and spoke Italian, but the care plan had no goals or interventions for communication barriers. Staff used gestures, simple words, and personal cell phones to translate, yet no communication devices, boards, or other alternative communication methods were available, and the DON confirmed the facility had no policy on communication needs.
Missed Nutritional Assessments After Significant Weight Loss: A resident with dementia, dysphagia, and CKD had severe cognitive impairment and required meal set-up/clean-up assistance. The resident experienced a 13% weight loss, but the RD did not complete timely quarterly or significant-change nutrition assessments, and estimated kcal, protein, and fluid needs were not reevaluated after the initial assessment.
Failure to provide ordered adaptive eating equipment: A resident with dementia, dysphagia, muscle weakness, and significant weight loss had a physician order for a plate guard and divided dish at all meals, but during lunch the meal was served on a regular plate with no plate guard. The DON verified the missing equipment and stated the ordered adaptive equipment was not listed on the meal ticket, and the RCN said the facility had no policy regarding adaptive equipment for meals.
Improper Handling of Contaminated PPE During EBP Care: A resident with a wound, ostomies, and moderate cognitive impairment required EBP during high-contact care. During assistance with dressing and a mechanical lift transfer, CNAs donned a reusable gown and gloves, then one CNA removed the gown and placed it on the floor instead of containing it properly. The DON stated the facility had no policy specifying how staff should remove and contain contaminated PPE.
Hazardous chemicals were found unsecured in a storage closet, posing a risk to seventeen cognitively impaired and independently mobile residents. An RN confirmed the closet was kept unlocked and was unsure of the locking requirement, later verifying it should have been locked.
A facility failed to administer oxygen according to physician orders for a resident with heart failure and shortness of breath. The resident was observed receiving oxygen at four liters per minute instead of the ordered two liters per minute. An LPN confirmed the incorrect setting, which was against the facility's policy requiring licensed nurses to verify and adjust oxygen settings.
The facility failed to document required physician visits for six residents, despite monthly NP visits. The residents, with conditions like dementia and chronic kidney disease, lacked evidence of physician visits over several months. The DON confirmed the visits occurred, but no documentation was available, violating the facility's policy on physician services.
A facility failed to maintain a safe and functional bed for a resident, compromising their right to a safe and comfortable environment. The bed's headboard and footboard were slanting outward, a condition present since the resident's admission. A nurse confirmed the issue and planned to consult maintenance. The resident had multiple diagnoses, including hypertension and anxiety.
A resident with severe cognitive impairment and multiple diagnoses developed a stage three pressure ulcer. Despite physician orders for daily wound care, an LPN documented the treatment as completed without actually performing it, leaving the dressing unchanged for two days. The facility's policy lacked guidelines for adhering to physician orders, leading to this deficiency.
A resident with a history of severe sepsis and UTI did not receive a scheduled dose of Caspofungin due to the medication being unavailable at the facility. The resident was alert and oriented, and the medication was part of a physician's order to continue treatment started in the hospital. Interviews confirmed the missed dose due to the facility's failure to have the medication on hand.
A resident with intact cognition and a history of dysphagia was found with seven medications left unattended on her bedside table. The RN confirmed routinely leaving medications with the resident, contrary to facility policy, which requires medications to be administered at the time of preparation and residents to be observed post-administration. The DON was unaware of this practice, and the resident had no orders to self-administer medications.
Lack of Functional Communication Support
Penalty
Summary
The facility failed to ensure a resident had a functional communication system in place. The resident was admitted with diagnoses including Alzheimer's disease, depression, and vascular dementia, and the quarterly MDS showed severe cognitive impairment, unclear speech, and that the resident was sometimes understood and sometimes could understand others. The care plan noted the resident needed help understanding instructions and written materials, with interventions to provide and explain detailed instructions in the resident's preferred language, ask simple questions to verify understanding, and clarify medical terminology, but it contained no goals or interventions addressing the resident's communication barriers and needs. Staff interviews and observations showed the resident spoke Italian and did not communicate with staff, who instead used gestures, simple words, and personal cell phones to try to translate. No communication devices, communication boards, or other alternative communication methods were available in the resident's room, and the DON confirmed none were in place and that the facility had no policy on communication needs. During an observation, an RN spoke to the resident in English and told the resident to sit down and that her daughter would arrive in two hours, while the resident continued trying to get up; the RN stated she knew what the resident wanted and confirmed there were no communication boards in the room. The SLP verified no alternative communication methods had been implemented, although she had made a memory book in 2024 with pictures of the resident's family and history, and the resident's family primarily communicated with the resident in Italian.
Missed Nutritional Assessments After Significant Weight Loss
Penalty
Summary
The facility failed to ensure nutritional assessments were completed timely for one resident reviewed for nutrition. The resident was admitted on 10/31/24 with diagnoses including dementia, dysphagia, muscle weakness, atrial fibrillation, and hypertensive chronic kidney disease. The quarterly MDS dated 12/31/25 showed severe cognitive impairment, set-up or clean-up assistance needed with meals, and no skin breakdown. The resident's weights showed 194 pounds on 01/05/25 and 168 pounds on 07/06/25, reflecting a 13% weight loss, with interventions including fortified foods and weekly weights; the resident later weighed 182 pounds on 04/06/26. Review of the nutritional assessments dated 11/04/24, 02/11/25, 05/09/25, 08/25/25, and 11/19/25 showed no quarterly nutritional assessment had been completed since 11/19/25. No nutritional assessment was completed after the resident experienced the significant weight loss, and the assessments did not include calculations of estimated caloric, protein, and fluid needs since the initial nutritional assessment. The RD verified in interview that the resident had a significant weight loss, had not had a quarterly nutritional assessment completed since 11/19/25, and had no documentation showing estimated caloric, protein, and fluid needs had been reevaluated since 11/04/24. The facility policy stated nutrition assessments would be completed on admission, quarterly, annually, and with significant changes and upon consultation.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure assistive adaptive equipment was provided during meals for Resident #8, who had diagnoses including dementia, dysphagia, muscle weakness, atrial fibrillation, and hypertensive chronic kidney disease. The resident’s quarterly MDS showed severe cognitive impairment and that the resident required set-up or clean-up assistance with meals. A physician order dated 08/20/25 directed use of a plate guard and divided dish at all meals, and the nutrition care plan noted significant weight loss with interventions to provide adaptive equipment as ordered. During lunch observation on 04/08/26, the resident was eating in the main dining room and the meal was served on a regular dinner plate with no plate guard. The DON verified the resident had a regular plate with no plate guard and stated the ordered adaptive equipment was not listed on the resident’s meal ticket. The RCN also stated the facility had no policies regarding adaptive equipment for meals.
Improper Handling of Contaminated PPE During EBP Care
Penalty
Summary
The facility failed to ensure personal protective equipment (PPE) was handled appropriately after use during Enhanced Barrier Precautions (EBP). Resident #10, admitted on 10/24/23, had diagnoses including paraplegia, lumbar spina bifida without hydrocephalus, end stage renal disease, ileostomy, and neuromuscular dysfunction of the bladder. The quarterly MDS dated 03/25/26 showed moderate cognitive impairment, dependence on staff for ADLs, and the presence of a urostomy, colostomy, and a surgical wound requiring treatment. The care plan dated 04/19/24 and physician order dated 12/11/24 directed staff to use EBP, including wearing a gown and gloves at a minimum, during high-contact care because of the wound with dressing. During observation on 04/08/26 at 10:24 A.M., CNA #408 and CNA #274 donned a reusable gown and gloves to assist the resident with putting on pants and transferring into a wheelchair via a mechanical lift. After the resident was safely placed in the wheelchair, CNA #408 removed the gown and placed it on the floor. During interview, CNA #408 stated the gown should have been placed in a container and not on the floor, and stated the contaminated PPE bin was full. CNA #408 also stated the container for the gowns was by the door and covered by a blanket belonging to the resident's roommate, and confirmed the roommate's blanket should not have been touching the contaminated PPE bin. The DON stated the facility did not have a policy specifying how staff should remove and contain contaminated PPE.
Hazardous Chemicals Unsecured in Storage Closet
Penalty
Summary
The facility failed to ensure that hazardous chemicals were securely stored, posing a potential risk to seventeen residents who were independently mobile and cognitively impaired. During an observation, a storage closet located behind a nursing desk was found unlocked, containing hazardous materials such as a can of disinfectant spray, germicidal disposable wipes, and a bottle of disinfectant solution, all labeled with cautionary warnings. A Registered Nurse (RN) confirmed that the storage closet was kept unlocked and was initially unsure if it was required to be locked. A follow-up interview with the same RN verified that the door to the storage closet was indeed supposed to be locked.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to ensure proper oxygen administration for a resident as per physician orders. Resident #5, who was admitted with diagnoses including heart failure and shortness of breath, had a physician order for oxygen at two liters per minute via nasal cannula as needed for oxygen saturation levels below 92 percent. However, observations on two consecutive days revealed that the resident's oxygen administration rate was set at four liters per minute, contrary to the physician's order. This discrepancy was confirmed during an interview with an LPN, who acknowledged that the oxygen rate should have been set at two liters per minute. The facility's policy on oxygen administration, revised in May 2018, requires verification of physician orders and adjustment of oxygen settings by a licensed nurse.
Failure to Document Required Physician Visits
Penalty
Summary
The facility failed to ensure that required physician visits were completed for six residents, as evidenced by a review of medical records, nurse practitioner (NP) progress notes, staff interviews, and facility policy. The residents affected had various medical conditions, including dementia, cellulitis, urinary retention, acute kidney failure, chronic kidney disease, anemia, and Alzheimer's disease. Despite being seen by an NP at least monthly, there was no documentation of physician visits for these residents over extended periods, ranging from several months to over a year. The Director of Nursing (DON) confirmed that the residents were reportedly seen by a physician, but the facility lacked any evidence, such as progress notes or other documentation, to verify these visits. The facility's policy, revised in 2016, stated that the attending physician was responsible for conducting required routine visits and supervising follow-up visits by NPs or physician assistants to ensure quality care. However, the absence of documented physician visits indicates a failure to adhere to this policy, affecting the quality of care provided to the residents.
Failure to Maintain Safe and Functional Bed
Penalty
Summary
The facility failed to maintain a safe and functional bed for a resident, which compromised the resident's right to a safe, clean, comfortable, and homelike environment. The deficiency was identified during an observation on November 18, 2024, when the resident was seen sitting in a wheelchair in their room. The headboard and footboard of the resident's bed were observed to be slanting outward from the bed frame. During a concurrent interview, the resident confirmed that the bed had been in this condition since their admission to the facility. A registered nurse verified the improper condition of the bed and indicated they would consult with maintenance to address the issue. The resident had been admitted with diagnoses including hypertension, gastroesophageal reflux disease, hyperlipidemia, arthritis, anxiety, and depression.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to complete wound care treatments per physician orders for a resident with a pressure ulcer. The resident, who had diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease, and polyneuropathy, was found to have a stage three pressure ulcer on the right heel. A physician order required daily cleansing and dressing of the wound, but the treatment administration record indicated that the treatment was documented as completed on a specific date by an LPN, despite the dressing being observed unchanged for two days. Upon observation, the wound dressing was dated two days prior, and the resident's pressure ulcer was unstageable with 100% eschar. The LPN admitted to not completing the wound dressing change but had documented it as done. The facility's policy on wound care did not provide guidelines for completing wound care per physician orders, contributing to the deficiency in care for the resident's pressure ulcer.
Medication Unavailability Leads to Missed Dose
Penalty
Summary
The facility failed to ensure that medications were available for administration as ordered by the physician, affecting a resident who was admitted with a history of severe sepsis, urinary tract infection (UTI), and chronic kidney disease. Upon admission, the resident was alert and oriented, with no documented cognitive issues. The resident was on antibiotic therapy for severe sepsis and UTI, and a physician order was in place for Caspofungin, an antifungal medication, to be administered daily. However, the medication was unavailable on 11/14/24, resulting in a missed dose. Interviews with the resident, the resident's daughter, and the Director of Nursing confirmed that the resident did not receive the Caspofungin as ordered on 11/14/24 due to the facility not having the medication available. The medication was initially started in the hospital and was to continue at the facility, but the delay in obtaining the medication led to a missed dose, which was verified by the Director of Nursing.
Unattended Medication Left with Resident
Penalty
Summary
The facility failed to ensure medications were not left unattended, affecting one resident. Resident #27, who had intact cognition, was observed in her room with seven medications left on a towel on her bedside table, without any staff present. The resident had no physician orders to self-administer medications, and her care plan included monitoring for signs of choking and aspiration due to impaired swallowing related to dysphagia. Registered Nurse (RN) #513 confirmed that she routinely left medications with the resident, despite the facility's policy requiring medications to be administered at the time they were prepared and residents to be observed to ensure the dose was ingested. The Director of Nursing (DON) was unaware of this practice and verified that Resident #27 had no orders to self-administer medications. The facility's policy, revised in November 2018, emphasized the importance of administering medications at the time of preparation and observing residents post-administration.
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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) |
|---|---|---|---|---|
| Embassy Of Willard | 1.9 mi | ★★★★★ | 2 | 0 |
| Crestwood Care Center | 11.1 mi | ★★★★★ | 0 | 0 |
| Shelby Pointe | 12 mi | ★★★★★ | 0 | 0 |
| Norwalk Memorial Home | 13.4 mi | ★★★★★ | 1 | 0 |
| Carecore At Gaymont | 13.7 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 July 2026) and official state health department websites.