Above 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 Willow Springs Care And Rehabilitation during CMS and state inspections, most recent first.
Failure to protect a resident from verbal and physical abuse occurred when two residents argued while waiting for breakfast and the conflict escalated into physical contact. One resident with MS and depression sustained skin tears to the arm after another resident with Parkinson’s disease, delusional disorder, and dementia grabbed the arm during the altercation; staff separated the residents after hearing yelling and seeing the contact.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Multiple areas, including shower rooms, resident bathrooms, and the laundry room, were found to be unsafe and unsanitary due to issues such as exposed drywall, broken fixtures, dirty surfaces, and non-functioning equipment. Staff interviews revealed inconsistent reporting and tracking of maintenance needs, with some repairs left incomplete or unaddressed for extended periods. Facility leadership acknowledged the deficiencies and the need for repairs and cleaning.
A resident with a history of heart failure and hypertension experienced a fall resulting in ongoing pain and a delayed diagnosis of a hip fracture. Despite multiple complaints of pain and increased use of pain medication, nursing staff did not notify the physician of the change in condition for four days, contrary to facility policy.
The facility did not review and validate PASARR screenings or send required Level 2 referrals for two residents with serious mental illness, despite documentation indicating the need for further assessment. The omissions included missing diagnoses and lack of evidence that the necessary referrals were made, as confirmed by the Social Service Director.
The facility did not accurately document actual nursing staff hours on daily postings for a majority of reviewed shifts, with posted hours not matching the hours actually worked. The ADON was unaware of these inaccuracies, which prevented residents, families, and visitors from knowing the true nursing staff hours.
The facility failed to reimburse personal funds to the State Office of Financial Recovery within 30 days for four deceased residents, as required by policy. The funds were returned late, ranging from 31 to 71 days after the deadline. The Business Office Manager acknowledged the process should have been completed within the stipulated timeframe.
The facility failed to review and validate PASARR for four residents, neglecting to send required Level 2 referrals for those with positive Level 1 screens indicating potential SMI or ID/DD. Staff interviews revealed a lack of awareness and process for ensuring PASARR accuracy, risking inappropriate placement and care for residents with mental health conditions.
The facility failed to discard expired medications from two medication carts and did not consistently monitor the medication storage refrigerator's temperature. Expired Albuterol inhalers, arthritis pain gel, ondansetron, and Ipratropium were found. The facility's policy required twice-daily temperature checks for vaccine storage, but only once-daily checks were documented, contrary to CDC guidance.
The facility failed to maintain effective infection control practices, as staff did not adhere to hand hygiene protocols or use appropriate PPE for residents on transmission-based precautions. Environmental cleaning was also inadequate, with stained furniture and soiled equipment not being properly disinfected. Additionally, non-EPA registered chemicals were used for cleaning resident rooms, including those on contact enteric precautions.
The facility failed to issue a written bed hold notice during hospital transfers for two residents, as required by their policy. One resident, who was cognitively intact, did not receive the notice, while another resident's power of attorney was informed of the transfer but not provided with the bed hold documentation. The DON acknowledged that the notice was not always completed during emergency transfers.
A facility failed to provide trauma-informed care for a resident with PTSD from military service. The resident's care plan lacked trigger-specific interventions, and trauma screenings did not document discussions of PTSD or triggers. Staff interviews revealed gaps in the trauma screening process, leading to inadequate identification and management of the resident's trauma-related needs.
A facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. Two residents received incorrect insulin administration due to staff not priming insulin pens and not holding the needle in the skin for the required time. The LPN involved was unaware of the correct procedure, and the DON confirmed the errors.
The facility failed to notify the LTC Ombudsman about the transfers of three residents, as required by their policy. Despite the policy mandating notification, there was no documentation for the transfers of residents with conditions such as COPD and diabetes. Interviews revealed that the Social Services Director was responsible for notifications but did not consistently provide them, and the Administrator confirmed the protocol was not followed.
A facility failed to effectively plan the discharge of a resident with a stroke, diabetes, and anxiety, who wished to return home. Despite being cleared by therapy and having caregiver support arranged, the discharge plan was not documented or executed. The resident's representative was hesitant due to legal issues with the home, leading to the resident staying long-term against their wishes. The lack of documentation and re-evaluation of discharge needs contributed to the deficiency.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal and physical abuse when two residents became involved in a verbal altercation that escalated into physical contact. One resident had diagnoses including multiple sclerosis and depression, with moderate cognitive impairment and wheelchair use, and was noted to enjoy socializing with staff and others. The other resident had diagnoses including Parkinson’s disease, delusional disorders, and dementia, with moderate impaired cognition and a care plan identifying verbal abusive outbursts toward staff and residents and directing that the resident be removed from the situation and taken to an alternative location. An incident report documented that while residents were waiting for the dining room to open for breakfast, the two residents argued and the interaction became physical, resulting in scratches to one resident’s arm. During later observation and interviews, the injured resident stated the other resident grabbed their arm after a confrontation, and the resident’s left forearm had a steri-strip dressing over a healing wound. Staff stated they heard yelling, saw the two residents in contact, and separated them; one staff member reported the injured resident had three bleeding skin tears on the left arm that were cleaned and steri-stripped. The administrator stated this was the first known physical incident involving the resident who initiated the contact.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Safe and Sanitary Resident and Laundry Areas
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in multiple areas, including two shower rooms, two resident bathrooms, and the laundry room. Observations revealed significant issues such as the presence of black slimy substances on shower walls, missing tiles exposing drywall, deep gouges in walls, loose grab bars, and unsanitary conditions including strong odors of urine and visible stains. In one shower room, the bathtub was used for storage of briefs, clothes, and other items, and the hand-washing sink and paper towel dispenser were found to be dirty and rusted. The resident bathroom had a cracked toilet seat with sharp edges, a smashed trash can with holes, and a hand-washing sink detached from the wall. Interviews with staff indicated a lack of awareness and inconsistent use of the facility's maintenance tracking system (TELS). The Administrator and Maintenance Director both stated that maintenance issues should be reported and tracked through TELS, but several staff members reported using informal methods such as verbal notifications or walkie-talkies. Maintenance staff were unaware of several of the observed deficiencies, and repairs to some items, such as the sink, were either temporary or incomplete. The Director of Nursing Services acknowledged that the shower rooms and restrooms were not in good functioning condition for resident use. In the laundry room, both the clean and dirty areas were found to be in disrepair, with broken washers and dryers, gaps under exterior doors, dirty floors and walls, moldy trim, and non-functioning ceiling vents filled with dirt and lint. The Laundry and Housekeeping Supervisor reported that the broken machines had been out of order for months and that there was no known plan for repair or replacement. Staff had resorted to makeshift solutions, such as using towels to block door gaps and duct tape to secure broken floor stripping. Facility leadership acknowledged the need for repairs and cleaning in the laundry room.
Failure to Notify Physician of Significant Change After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident following a fall. The resident, who had a history of heart failure and hypertension, was found on the floor in their room and subsequently complained of pain in the right arm and hip. Despite repeated complaints of pain and administration of Tylenol for pain management, there was no documentation that the physician was notified of the fall, the new pain complaints, or the increased use of pain medication for four days. An x-ray was not ordered until four days after the fall, at which point a right hip fracture was identified. Interviews with staff and review of records confirmed that the nurse on duty did not notify the physician as required by facility policy, which mandates immediate notification of the physician for any significant change in a resident's condition. The resident and their representative both reported ongoing pain and a delay in diagnostic intervention. The Director of Nursing Services acknowledged that the expectation was for immediate physician notification following such incidents, and that this protocol was not followed in this case.
Failure to Complete Required PASARR Level 2 Referrals for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents with mental health diagnoses. For one resident admitted with major depressive disorder, insomnia, and post-traumatic stress disorder (PTSD), the PASARR documented depression but omitted PTSD and insomnia, and there was no evidence that a required Level 2 referral was sent for further evaluation. For another resident admitted with major depressive disorder, bipolar disorder, anxiety disorder, and borderline personality disorder, the PASARR indicated the presence of serious mental illness (SMI) and noted that a Level 2 referral was required, but no evidence of such a referral was found in the medical record. The facility's policy required that if a Level 1 PASARR indicated possible SMI, intellectual disability (ID), or related disorder (RD), a Level 2 referral should be made to the state PASARR representative for further assessment. The Social Service Director acknowledged responsibility for reviewing PASARRs on admission and sending Level 2 referrals when indicated, but admitted that the required process was not followed for these two residents. This lapse was identified during a review of records and staff interview.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to accurately document the actual hours worked by nursing staff on the daily nurse staffing postings for 27 out of 45 shifts reviewed between 07/01/2025 and 07/15/2025. Record review showed that the posted nursing hours did not match the actual hours worked by nursing employees on these shifts. During an interview, the Assistant Director of Nursing stated they were unaware that the daily nurse postings were inaccurate and expected the postings to reflect the actual hours worked. This discrepancy prevented residents, family members, and visitors from knowing the true nursing staff hours.
Delayed Reimbursement of Deceased Residents' Funds
Penalty
Summary
The facility failed to ensure that personal funds of deceased residents were reimbursed to the State Office of Financial Recovery (OFR) within the required 30-day timeframe. This deficiency was identified for four residents who had passed away, with their personal funds remaining in the facility's trust accounts. The facility's policy mandates that personal funds should be returned to the OFR within 30 days of a resident's death if the resident received long-term care services paid by the department. For Resident 252, who passed away on June 8, 2024, the $100.08 in personal funds was not returned to the OFR until August 21, 2024, which was 44 days late. Similarly, Resident 253, who died on May 12, 2024, had $40.33 returned 71 days late. Resident 254's funds of $70.79 were returned 31 days late after their death on February 17, 2024. Lastly, Resident 255, who passed away on May 17, 2024, had $1678.83 returned 66 days late. The Business Office Manager acknowledged that the process was to return funds within 30 days and that these delays should not have occurred.
Failure to Validate PASARR and Send Level 2 Referrals
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for four residents, which is essential to ensure individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) are not inappropriately placed in nursing homes. Specifically, the facility did not send the required Level 2 referral for residents who had a positive Level 1 PASARR, indicating potential SMI or ID/DD. This oversight was identified in the cases of four residents who had various diagnoses such as depression, anxiety, insomnia, bipolar disorder, and schizoaffective disorder. The PASARR documentation for these residents was either incomplete or not updated to reflect all relevant diagnoses, and no evidence of Level 2 referrals was found in their medical records. Interviews with facility staff revealed a lack of awareness and understanding of the PASARR process. The Social Service Director and Assistant admitted they were unaware that a positive SMI indicator on a PASARR required a Level 2 evaluation before admission. They also acknowledged that they did not have a process in place to review PASARR documents for accuracy. The Director of Nursing Services was also unaware of the PASARR process, indicating a systemic issue within the facility regarding compliance with PASARR regulations. This lack of proper procedure and oversight placed residents at risk of not receiving appropriate care and services for their needs.
Expired Medications and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure that expired medications were discarded from two of the three medication carts, specifically Team 1 and Team 3. During an observation, it was found that Team 1's medication cart contained four expired Albuterol inhalers and two expired tubes of arthritis pain gel. Similarly, Team 3's medication cart had two expired bottles of ondansetron and one expired pack of Ipratropium. Staff members, including LPNs, acknowledged that expired medications should be disposed of and reordered as necessary, but this was not consistently done. Additionally, the facility did not consistently monitor the temperature of the medication storage refrigerator, which contained vaccines. The policy required twice-daily temperature checks, but the facility only documented temperatures once daily. This inconsistency was noted after the facility received new vaccines, including pneumococcal and influenza vaccines. The Director of Nursing Services confirmed that the facility's process involved night shift nurses checking and recording the temperature once a day, which did not align with the policy or CDC guidance.
Inadequate Infection Control and Environmental Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Staff members did not adhere to hand hygiene protocols, particularly when exiting isolation precaution rooms. For instance, a housekeeper and a housekeeping supervisor were unaware of the requirement to wash hands with soap and water after exiting a C. diff positive room, opting instead to use hand sanitizer. Additionally, a Licensed Practical Nurse (LPN) was observed administering medications and handling equipment without performing hand hygiene between tasks, which is a critical step in preventing the spread of infections. The facility also failed to implement appropriate transmission-based precautions (TBP) for residents requiring such measures. Two residents, one with a multidrug-resistant organism and another with an indwelling catheter, were not provided care with the necessary personal protective equipment (PPE) by staff. Nursing assistants and the Director of Rehabilitation were observed assisting these residents without wearing gowns or gloves, despite the presence of signage indicating the need for contact precautions and enhanced barrier precautions. Environmental cleaning and disinfection practices were inadequate, as evidenced by the condition of furniture and resident equipment. Chairs and sofas in common areas were stained and not cleaned regularly, and sit-to-stand machines used for resident transfers were visibly soiled and not disinfected between uses. Furthermore, the chemicals used for cleaning resident rooms, including those on contact enteric precautions, were not EPA-registered disinfectants, which are necessary for effectively reducing the risk of infection transmission. Staff responsible for cleaning were unaware of the appropriate disinfectants to use, and the facility's leadership did not ensure the use of proper cleaning agents.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of bed hold to two residents during their transfer to the hospital, which is a requirement according to the facility's Bed Hold Policy Notification 2024. Resident 7, who was cognitively intact and required substantial assistance for activities of daily living, was transferred to the hospital without receiving the bed hold policy to review and sign. This omission was confirmed during an interview with Resident 7, who stated that they did not receive the necessary documentation at the time of their hospital transfer. Similarly, Resident 9, who had a history of stroke, respiratory disease, and heart disease, and required substantial assistance for daily activities, was transferred to the hospital without a bed hold notice being documented in their medical record. Although the resident's power of attorney was notified of the transfer, the bed hold notice was not completed. The Director of Nursing Services acknowledged that in cases of emergency transfers, the bed hold notice was not always completed, though it should have been sent to the resident or their representative within 24 hours of the transfer.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident with a history of trauma, specifically Post Traumatic Stress Disorder (PTSD) resulting from military service in the Vietnam War. The resident, who was admitted with diagnoses including insomnia and PTSD, had a comprehensive assessment indicating severely impaired cognition and required extensive assistance for activities of daily living. However, the resident's care plan did not include trigger-specific interventions or identify the resident's triggers, despite the risk of depression and PTSD being noted. The facility's policy on trauma-informed care required social services staff to be trained on screening and identifying triggers associated with re-traumatization. However, the trauma screenings conducted for the resident did not document any discussion of the resident's PTSD diagnosis or person-centered triggers. Interviews with staff revealed that the trauma screening process involved interviewing or using trauma-related questions, but the resident did not disclose any trauma. The Director of Nursing Services stated that the expectation was for staff to ensure timely completion and follow-up of trauma screenings, which was not adequately done in this case.
Medication Administration Errors with Insulin Pens
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12% error rate during a survey. This was identified through observations, interviews, and record reviews involving two residents out of six observed during 25 medication administration opportunities. The errors were related to the improper administration of insulin using insulin pens. Specifically, the staff did not follow the correct procedure for priming the insulin pen and holding the needle in the skin for the required duration, as outlined in the facility's policy and the U.S. Food and Drug Administration's instructions for use. Resident 21, who has diabetes and dementia, was administered insulin incorrectly when the LPN held the needle in the skin for only three seconds instead of the required time. Similarly, Resident 43, who has diabetes, heart disease, and depression, received insulin without the pen being primed, and the needle was held for only three seconds. The LPN involved was unaware of the priming requirement and did not count the time the needle was held in the skin. The Director of Nursing Services confirmed that the nurses should have been priming the insulin pen and holding the needle for the correct duration to ensure accurate dosing.
Failure to Notify LTC Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman about the transfer or discharge of three residents, which is a requirement according to their policy. The policy, titled 'Admission, Transfer and Discharge - Facility Initiated Transfers and Discharges,' mandates that a copy of the notice of transfers or discharges be sent to the Ombudsman. However, for Residents 2, 3, and 4, there was no documentation indicating that such notifications were made. Resident 2, who was cognitively intact, was transferred to an emergency room for evaluation and treatment without the Ombudsman being informed. Similarly, Resident 3, also cognitively intact, was transferred to an acute care hospital, and Resident 4, with moderately impaired cognition, was transferred to an acute care hospital emergency room, both without the required notification. Interviews with facility staff revealed inconsistencies in the notification process. The Regional LTC Ombudsman confirmed that they had not received any notices of transfers or discharges from the facility for some time. Staff B, the Social Services Director, admitted responsibility for notifying the Ombudsman but acknowledged that notifications were not consistently provided. Staff A, the Administrator, stated that the facility protocol required weekly transmission of transfer/discharge notices to the Ombudsman, which was not adhered to, leading to the deficiency.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for Resident 5, who was admitted with diagnoses including a stroke, diabetes, and anxiety. The comprehensive assessment indicated that Resident 5 required moderate to maximum assistance for activities of daily living and had moderately impaired cognition. Despite Resident 5's expressed goal to return home, with arrangements made for caregiver support, the discharge plan was not executed, and there was no documentation of a discharge care plan in the resident's medical record. Interviews revealed that the Social Services Director (SSD) was responsible for the discharge process but had not engaged in further discharge planning with Resident 5 since June 2024. The SSD acknowledged that the resident's representative was hesitant about the discharge due to legal issues with Resident 5's home, and no safe discharge location was identified. The facility's administrator confirmed awareness of the discharge issues and stated that the resident was cleared by therapy to return home. However, the decision for Resident 5 to stay long-term in the facility was made by the resident's representative/Power of Attorney, despite the resident's desire to return home. The lack of documentation and re-evaluation of discharge needs in the medical record contributed to the deficiency, as the facility did not involve the interdisciplinary team or address the resident's goals and needs effectively.
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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 149 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yakima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summitview Rehab And Health Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Crescent Health Care | 2.5 mi | ★★★★★ | 19 | 0 |
| Landmark Care And Rehabilitation | 2.6 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Health Care Ctr | 4 mi | ★★★★★ | 17 | 0 |
| Garden Village | 4.3 mi | ★★★★★ | 34 | 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.