Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Willowbrook Nursing Center during CMS and state inspections, most recent first.
Multiple staff failed to follow infection control and hand hygiene protocols during resident care and meal tray distribution, including not changing gloves or sanitizing hands between tasks and residents. These lapses occurred despite staff being trained and aware of facility policies, and involved residents with significant care needs and cognitive impairment.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with dementia and personality changes had documented incidents of inappropriate remarks and behaviors toward staff, but these behaviors were not reflected in the resident's MDS quarterly assessment. Despite clinical notes indicating such behaviors during the assessment period, the MDS was coded as if no behavioral symptoms were present, contrary to RAI manual instructions. Facility staff acknowledged that this inaccuracy could impact care planning.
Two residents who were dependent on staff for personal hygiene were observed with long, jagged, and dirty fingernails over multiple days, despite expressing a desire for nail care. Staff interviews confirmed that nail care was the responsibility of CNAs for non-diabetic residents and should be performed daily, but this was not done according to facility policy.
Two residents who required total assistance with transfers were found using mechanical lift slings that were worn, with faded or unreadable labels, indistinguishable loop colors, and fraying. Staff interviews revealed uncertainty about proper sling inspection and removal criteria, and manufacturer guidelines indicated such slings should be immediately removed from use.
A resident with severe cognitive impairment and a physician order for nectar thickened liquids was repeatedly provided with regular water at the bedside. Staff and a family member were unclear about the dietary requirements, and there was no visual identification system in place to alert staff to the resident's need for thickened liquids, leading to the resident receiving food and fluids not prepared to meet individual needs.
Two residents with moderate cognitive impairment were found with medications left on their bedside tables without physician orders or care plans authorizing self-administration. Staff and family interviews confirmed that medications were not always administered as prescribed, and facility policy prohibits leaving medications at bedside. Facility leadership and staff acknowledged that all medications should be administered by licensed personnel, and records showed that these procedures were not followed.
A resident with dementia from a secure unit was left unattended in a transport van, leading to elopement. The facility failed to inform the transport staff of the resident's need for supervision, resulting in the resident walking away and being found by a good Samaritan. The lack of communication and policy for transporting residents with dementia led to this deficiency.
The facility failed to remove worn and damaged mechanical lift slings from service, posing potential safety risks to residents. Observations showed residents using slings with faded colors and unreadable labels, indicating wear. Staff interviews revealed a lack of awareness about inspecting slings for safety, and the facility's policy did not address this issue.
The facility failed to maintain a sanitary environment for residents, as observed in three rooms. A resident's restroom had splatter stains and a strong urine odor, another resident's room had crumbs and splatters, and a third resident's divider curtain was soiled. Interviews revealed that housekeeping did not adhere to cleaning policies, and staff were unaware of these conditions.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled and expired food found in the refrigerator, freezer, and dry storage. Interviews revealed that the dietary manager was responsible for oversight, but despite staff training, proper labeling and storage practices were not consistently followed, posing a risk of foodborne illness.
The facility failed to maintain an effective pest control program, leading to a fly infestation in two hallways and resident rooms. Observations showed flies on floors, walls, and doorways, with residents reporting the issue as ongoing. Staff interviews revealed awareness of the problem, but the facility lacked specific treatments for flies, despite bi-monthly pest control visits. The facility's policy required an effective pest control program, but current measures were inadequate.
The facility failed to maintain a three-compartment sink in the kitchen, leading to a persistent leak that was not properly addressed. The Dietary Manager reported the issue to the Maintenance Director, who attempted repairs, but the leak continued. The kitchen staff was unaware of the ongoing problem, indicating a lack of communication and follow-up on maintenance issues.
Two residents in a LTC facility were not accurately assessed using the MDS, leading to deficiencies in their care plans. One resident, with severe cognitive impairment and a history of stroke, was not coded as dependent with transfers, while another resident receiving hospice care was not coded as such in the MDS. Facility staff, including the MDS coordinator and DON, acknowledged the inaccuracies and the lack of verification for the assessments' accuracy.
A facility failed to ensure a resident's enteral feeding formula was maintained within the manufacturer's date, risking potential health complications. The resident, dependent on a feeding tube due to cerebrovascular disease, had expired formula at their bedside. LVNs and the DON confirmed the formula should be disposed of within 24 hours, but this was not done, despite the facility's policy requiring timely disposal.
A resident in an LTC facility did not receive her prescribed Clonazepam 1 mg BID for several days due to a breakdown in communication and process. Despite the medication being available in the Pyxis machine, it was not administered from June 12 to June 17. Staff interviews revealed confusion about the medication's availability and alleged refusals, which the resident denied. The issue was resolved when the medication was finally administered starting June 18.
The facility failed to provide adequate emergency call light systems in the bathrooms of two residents, with cords too short to be reachable from the floor. One resident, with severe cognitive impairment and multiple health issues, had a 5-inch cord, while another resident with diabetes and hypertension had a 12-inch cord. Both lengths were insufficient for reaching in case of a fall, posing a risk to resident safety.
The facility did not post required nurse staffing information, as observed on multiple occasions. The staffing coordinator was unaware of the requirement, and the DON and administrator failed to ensure compliance. This oversight could mislead residents and visitors about staffing levels.
Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for multiple residents and staff, as evidenced by direct observations, interviews, and record reviews. One incident involved a female resident with severe cognitive impairment and total dependence on staff for toileting hygiene, who required an indwelling catheter and was always incontinent of bowel. During incontinent care, a CNA removed soiled gloves and applied clean gloves without performing hand hygiene, then continued to provide care and adjust the resident's linens and bed with soiled gloves. The CNA acknowledged awareness of the correct procedure but did not follow it during the observed care. Additional deficiencies were observed during meal tray distribution and resident care. One CNA passed trays to all residents on a hall without sanitizing her hands between residents, despite having direct contact with residents and their personal items. Another CNA was observed leaving a resident's room with gloves on, retrieving a clean gown from a linen cart, and returning to the room to continue care and set up a meal tray, all without removing or changing gloves or performing hand hygiene. Both CNAs admitted to knowing the correct protocols but failed to follow them, citing being rushed or forgetting. Further, another CNA was observed passing and setting up meal trays for multiple residents and feeding a resident without performing hand hygiene between tasks. Interviews with staff and leadership confirmed that hand hygiene is expected before and after resident contact, between tasks, and before feeding residents. Facility policies reviewed also required hand hygiene at these critical points, but these procedures were not consistently followed by staff during the survey period.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Accurately Reflect Resident Behaviors in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) quarterly assessment accurately reflected the resident's behavioral status. Specifically, the MDS assessment for a male resident with dementia, personality change, and hypertension did not indicate the presence of physical or verbal behaviors, despite documentation in the clinical record showing that the resident had exhibited inappropriate remarks and behaviors toward staff during the assessment's look-back period. Behavior notes from nursing staff documented incidents of inappropriate remarks to a female medication aide and inappropriate behavior toward a nurse, with interventions such as redirecting the resident to his room. The MDS Coordinator confirmed that the facility follows the RAI manual for assessments and acknowledged that inaccurate MDS completion could result in care needs not being properly addressed in the care plan. The Assistant Director of Nursing (ADON) stated that the Director of Nursing (DON) is responsible for ensuring MDS accuracy, and the Clinical Services Director emphasized that behavioral symptoms should be captured in the MDS to ensure appropriate care planning. The RAI manual specifies that behavioral symptoms present in the last seven days should be coded accordingly, but this was not done for the resident in question.
Failure to Provide Necessary Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to personal hygiene for two residents who were unable to perform these tasks independently. One resident with a history of stroke and moderately impaired cognition was observed on two consecutive days with long, jagged fingernails and a brown substance caked underneath them. This resident expressed a desire to have his nails cleaned, trimmed, and filed, stating it would make him feel better. The resident's care plan noted an ADL self-care performance deficit but did not include specific interventions for personal hygiene or nail care. Another resident, diagnosed with Parkinson's Disease and peripheral vascular disease and with severely impaired cognition, was also observed on two consecutive days with long, jagged fingernails in need of trimming and filing. This resident was dependent on staff for personal hygiene and expressed a wish to have his nails trimmed. Staff interviews revealed that CNAs were responsible for nail care for non-diabetic residents and that nail care was typically performed during showers. However, the staff were unsure why nail care had not been completed for these residents. Facility policy required daily cleaning and regular trimming of nails, but this was not followed for the two residents identified.
Failure to Remove Damaged Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for two residents who required total assistance with transfers due to severe cognitive impairment and dependence in all activities of daily living. Observations revealed that both residents were using mechanical lift slings that were worn and damaged. One resident was observed in a Geri-chair with a blue mesh sling that had crinkled, faded, and unreadable labels, indistinguishable loop colors, and fraying on the black webbing. Another resident's wheelchair contained a sling with faded loops and tag. Interviews with staff indicated a lack of awareness regarding the condition of the slings and the criteria for removing them from service. The LVN was unsure about the safety of using slings with faded loops, and the ADON acknowledged uncertainty about whether CNAs knew what to look for when inspecting slings. The Housekeeping Supervisor described the laundering process and stated that slings were inspected for damage before being returned for use. The Clinical Services Director confirmed that slings should be removed from service if labels were unreadable or if there were signs of wear and tear. Manufacturer guidelines reviewed by surveyors specified that slings with signs of wear, color fading, or improper laundering should be immediately removed from use.
Failure to Provide Prescribed Thickened Liquids to Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of senile degeneration of the brain and a history of difficulty swallowing was not consistently provided with food and liquids in the prescribed form. The resident's care plan and physician orders required nectar thickened liquids, but observations on two separate days revealed that regular water was present at the bedside. A family member admitted to giving the resident regular water, believing it was acceptable since it was available in the room, but acknowledged the resident had difficulty swallowing and agreed to stop after being informed. Staff interviews revealed a lack of clear identification or visual cues for residents requiring thickened liquids. The hospitality aide responsible for passing water was unaware of the importance of providing only thickened liquids to certain residents and believed, based on unclear communication, that both regular and thickened water could be given. The DON confirmed that staff were expected to know which residents required thickened liquids based on reports, but no visual system was in place to assist with this. Facility policy required an identification system to ensure residents received the ordered diet, but this was not implemented, resulting in the resident being served inappropriate liquids.
Failure to Ensure Proper Medication Storage and Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that medications were stored and administered according to physician orders and facility policy. Two residents with moderate cognitive impairment and diagnoses including dementia and other neurological conditions were found with medications left on their bedside tables. Neither resident was care planned or had a physician order to self-administer medications or to have medications at bedside. Observations and interviews confirmed that these medications, including both oral and topical forms, were accessible to the residents without appropriate authorization or supervision. Record reviews showed that the care plans for both residents specified that medications should be administered by staff as ordered by the physician. Despite this, medications such as aspirin, calcium carbonate, ferrous gluconate, and a topical muscle and joint cream were found in the residents' rooms. One resident expressed confusion about whether she had taken her medication, and a family member reported finding untaken medications left at the bedside on multiple occasions. Staff interviews consistently indicated that medications should not be left in resident rooms and that all medications must be administered by licensed personnel or medication aides. Facility policies and recent inservice training reinforced that medications are not to be left at the bedside and must be administered safely and as prescribed. The Director of Nursing and the administrator both stated that no residents were authorized to self-administer medications or have them at bedside, and that any such occurrences should be addressed immediately. The failure to follow these procedures resulted in medications being left unattended in resident rooms, contrary to facility policy and physician orders.
Failure to Provide Adequate Supervision During Resident Transport
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. This deficiency was identified in the case of a resident with dementia who resided on a secure unit. The facility did not notify the transport staff that the resident had a diagnosis of dementia and required supervision during transport. As a result, the resident was left unattended in a transport van for approximately 15 minutes, during which time the resident eloped from the van and walked down the road. The transport driver was unaware that the resident was from the secure unit and had dementia, as there was no communication from the facility regarding the resident's need for supervision. The transport driver assumed the resident could be left unattended and left the resident in the van while retrieving another resident from a hospital. The resident was later found by a good Samaritan and returned to the facility by the police, with no injuries noted. Interviews with facility staff revealed that there was a lack of communication and understanding of the need for supervision for residents with dementia during transport. The facility did not provide adequate information to the transport company about the resident's condition, and there was no policy in place to ensure that residents from the secure unit were accompanied by a staff member during transport. This oversight led to the resident's elopement and the identification of an Immediate Jeopardy situation.
Failure to Remove Worn Mechanical Lift Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. Observations revealed that several residents were using mechanical lift slings with faded colors and unreadable labels, indicating wear and potential safety risks. The Director of Nursing (DON) was unaware that color fading meant the slings should not be used, and acknowledged that CNAs should check slings for safety before use. Resident #3, a female with severe cognitive impairment and dependent on staff for transfers, was observed with a sling that had its label cut off and faded straps. Resident #58, who had no cognitive impairment but was dependent on mechanical aid for transfers, was using a sling with faded straps and an unreadable label. Resident #86, with severe cognitive impairment and a history of stroke, was observed in a Geri chair with a sling that had faded straps. Resident #111, dependent on a Hoyer lift for transfers, was observed with a sling that had faded loops. Interviews with staff revealed a lack of awareness regarding the importance of inspecting slings for wear and tear. A CNA admitted to using a sling that should have been replaced, and the laundry aide was unaware that color fading was a sign of improper laundering. The facility's policy on using portable lifting machines did not address inspecting slings for wear, and manufacturer guidelines clearly stated that slings showing signs of wear or improper laundering should be removed from use immediately.
Failure to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the conditions in the rooms of three residents. Resident #30's restroom was found with dark-colored splatter stains on the wall next to the toilet and a strong odor of urine. Resident #71's room had crumbs in the windowsill and splatters on the wall, which the resident identified as food and stated that housekeeping never cleaned. Resident #43's divider curtain was soiled with a dark substance and had large splatter stains. These observations were made during specific dates and times, and interviews with the residents confirmed the lack of cleanliness. Interviews with facility staff, including the housekeeping supervisor and the Director of Nursing (DON), revealed that the housekeeping staff was responsible for daily cleaning, but there was no set schedule for cleaning certain items like divider curtains. The housekeeping supervisor acknowledged that food crumbs could attract pests, and the DON was unaware of the unsanitary conditions in the residents' rooms. The facility's policies on cleaning were reviewed, indicating that daily cleaning should include spot-cleaning of walls and other surfaces, but these were not adhered to, leading to the unsanitary conditions observed.
Sanitation Deficiencies in Kitchen Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The walk-in refrigerator contained a clear plastic container labeled chili and another with diced yellow onions, both dated, but the walk-in freezer had multiple items such as pork breakfast sausage patties, French fries, peas, and mixed vegetables that were unlabeled and undated. Additionally, food items were improperly stored on the floor of the walk-in freezer. In the dry storage area, a yellow cake mix was found with an expired date, and a container of dill pickles was improperly sealed and unlabeled. Interviews with the dietary manager (DM) and the administrator revealed that the DM was responsible for kitchen oversight, including ensuring that food items were labeled, dated, and stored correctly. Both acknowledged that consuming expired food could lead to foodborne illness. Despite staff training on sanitation, labeling, and dating, these practices were not consistently followed, as evidenced by the findings. The facility's policy on food storage was not adhered to, which requires all food items to be stored above the floor, wrapped or in covered containers, labeled, and dated to prevent cross-contamination.
Facility Fails to Control Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in two of its hallways and two resident rooms. Observations revealed flies crawling on the floors, walls, and doorways of hallways 100 and 500, as well as in specific rooms. Residents reported the presence of flies as a persistent issue, with one resident using a fly swatter to manage the problem. The facility's pest control program, managed by the maintenance director, involved bi-monthly visits from a pest control company, but there was no specific treatment for flies documented in the reports from January to June 2024. Interviews with facility staff, including the housekeeping supervisor and maintenance man, indicated awareness of the fly issue, which had been ongoing for about a month. The administrator acknowledged the problem and noted that the facility lacked certain pest control measures, such as blue lights or blowers on all exit doors. The facility's policy, revised in May 2008, stated the need for an effective pest control program to keep the building free of insects and rodents, yet the current measures were insufficient to address the fly infestation.
Leaking Kitchen Sink Not Properly Maintained
Penalty
Summary
The facility failed to maintain the three-compartment sink in the kitchen in safe operating condition, as observed on June 17, 2024. The right side of the sink was leaking water into a tub placed underneath and onto the floor, creating a large puddle of soapy water. The Dietary Manager (DM) was unaware of how long the tub had been there and mentioned that the Maintenance Director had previously fixed the sink. However, the leak persisted, and the DM had reported the issue to the Maintenance Director on June 12, 2024. The cook also did not notice the tub or the leak, indicating a lack of awareness among the kitchen staff. The Maintenance Director stated that he had applied new plumbers' putty and a strainer basket on June 12, 2024, but was not aware that the sink continued to leak afterward. The administrator confirmed that it was the Maintenance Director's responsibility to ensure equipment was in good working order and that the DM was responsible for reporting needed repairs. The facility's policy required the Dining Services Director to submit maintenance requests and notify the administrator when repairs were completed. However, the ongoing leak and the presence of the tub under the sink suggest a breakdown in communication and follow-up on maintenance issues.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to conduct comprehensive and accurate assessments for two residents, leading to deficiencies in their care plans. Resident #86, a female with severe cognitive impairment and a history of stroke, was not coded as dependent with transfers in her quarterly MDS assessment. Despite being observed in a Geri chair with a mechanical lift sling, indicating dependency, her care plan did not specifically address her ADL needs and supervision required. This oversight was acknowledged by the MDS coordinator, who admitted to missing the accurate coding before submission. Resident #114, a male with a terminal prognosis and receiving hospice care, was not coded as receiving hospice services on his admission MDS assessment. His care plan included hospice care interventions, but the MDS assessment failed to reflect this, which was confirmed by the MDS coordinator. The coordinator admitted to missing the hospice care coding and acknowledged that a significant change MDS assessment should have been completed when the resident was admitted to hospice care. Interviews with facility staff, including the MDS coordinator, DON, and Administrator, revealed a lack of verification for the accuracy of MDS assessments. The DON signed off on the assessments without verifying their accuracy, and the Administrator indicated that the regional MDS person was responsible for ensuring accuracy. The failure to accurately complete the MDS assessments could potentially affect the facility's reimbursement rates and the residents' care, as the care plans are triggered by these assessments.
Failure to Maintain Enteral Feeding Formula Within Date
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding through a gastrostomy tube was provided with appropriate treatment and services to prevent complications. Specifically, the facility did not maintain the enteral feeding formula within the date specified by the manufacturer, which could potentially place the resident at risk for sickness, hospitalization, and decline in health. The resident in question, a female with cerebrovascular disease, was dependent on a feeding tube and required assistance with all activities of daily living. Observations and interviews revealed that the enteral feeding formula container at the resident's bedside was opened beyond the recommended usage period. Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) acknowledged that the formula should be disposed of within 24 hours of opening to prevent potential health risks. However, it was noted that the formula was not disposed of in a timely manner, and the charge nurses and unit managers were responsible for ensuring the feedings were within date before administration. The facility's policy on enteral nutrition emphasized providing adequate nutritional support as ordered, yet this was not adhered to in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free of significant medication errors, specifically regarding the administration of Clonazepam. The resident, a cognitively intact female with a history of chronic pain, anxiety disorder, and hypertension, was not administered her prescribed Clonazepam 1 mg twice daily from June 12 to June 17, 2024. The medication administration record indicated various reasons for the missed doses, including blanks, drug refusal codes, and notes to see nurses' notes, yet there was no documentation in the nurses' notes about the medication being refused or unavailable. Interviews with staff revealed a breakdown in communication and process. Medication Aide H stated that the Clonazepam had not been received from the pharmacy since the resident's return from the hospital, and she had requested RN G to retrieve it from the Pyxis machine, which she did not have access to. RN G confirmed that the medication had been ordered but not arrived, and claimed the resident had been refusing it, although the resident herself denied refusing the medication and stated she was told it had not been received. Further interviews with the Director of Nursing (DON) and the Administrator highlighted that the medication should have been available in the Pyxis machine for emergency use. The DON and Administrator both expressed that the medication should have been administered as ordered, and the DON noted that she could have expedited the medication's arrival if informed. The Unit Manager later acknowledged a communication breakdown and stated that the medication was available in the Pyxis until the new prescription was filled. The resident eventually received her medication starting June 18, 2024.
Inadequate Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the emergency call lights in the bathrooms of two residents were equipped with cords long enough to be reachable from the floor, which is necessary for residents to call for assistance in case of a fall. Resident #90, a female with severe cognitive impairment and a history of atrial fibrillation, Alzheimer's disease, and breast cancer, was observed to have a call light cord in her bathroom that was only 5 inches long. This length was insufficient for her to reach in the event of a fall, despite her being independent with toileting and having no recent falls. Similarly, Resident #70, a female with Type II Diabetes and hypertension, was observed to have a call light cord in her bathroom that was only 12 inches long when unwound. She reported using the restroom with limited assistance and had a history of falls, although not recent. The facility's maintenance director acknowledged responsibility for ensuring the functionality and appropriate length of call lights, but the deficiency was noted during the survey. The facility's policy on answering call lights, revised in 2010, emphasizes the importance of having a call system in the bathroom, yet the deficiency was observed.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors, as required by regulations. On 6/17/2024, during observations at 8:45 am and 11:40 am, no nurse staffing information was posted in the facility. The staffing coordinator, during an interview, admitted to posting only the working schedule on the bulletin board and was unaware of the requirement to post detailed nurse staffing information for each discipline. This oversight was attributed to the training he received from the previous staffing coordinator. The Director of Nursing (DON) acknowledged that the staffing coordinator was responsible for posting the staffing information and admitted that she should have ensured it was done. The administrator also confirmed that the staffing coordinator was responsible for posting the information and mistakenly believed that the schedule on the bulletin board was sufficient. There was no policy in place for posting nurse staffing information, and the administrator was unsure when the information was last posted. This lack of posting could lead residents, families, and visitors to believe there were insufficient staff present to provide care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nacogdoches
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stallings Court Nursing And Rehabilitation | 0.4 mi | ★★★★★ | 4 | 0 |
| Westward Trails Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 1 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Wells Ltc Nursing & Rehabilitation | 20.3 mi | ★★★★★ | 17 | 4 |
| Southland Rehabilitation And Healthcare Center | 21.8 mi | ★★★★★ | 9 | 0 |
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