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 Ridge Healthcare during CMS and state inspections, most recent first.
Food storage and sanitizer monitoring were not maintained in a sanitary manner. A scoop was left in the flour bin and another was left in the sugar bin, despite staff stating scoops should be cleaned and returned to the dishwasher. Surveyors also found repeated missed and out-of-range PPM checks for the red bucket sanitizer log, with unclear follow-up and no policy produced during the survey.
The facility did not ensure that an RN was screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. The RN completed a BID and reported living in Minnesota within the last 3 years, but the facility ran only the WI background check and did not complete the MN check before surveyors arrived. The BOM stated the out-of-state background check was missed and that the RN's background was not complete.
A facility failed to develop and implement sleep hygiene care plans for two residents who had melatonin ordered for insomnia. One resident had diagnoses including CVA, DM2, anxiety, aphasia, hemiplegia, narcolepsy, and AFib, and a sleep assessment noted 7-8 hours of sleep with a goal of 8 hours, but no non-pharmacological sleep interventions were included in the care plan. Another resident with encephalopathy, weakness, late-onset Alzheimer's disease, depression, anxiety, and CKD 3b also had melatonin orders, and an RN stated no sleep care plan had been developed for either resident.
A resident with DM2, vascular dementia, and adult failure to thrive did not receive insulin in accordance with physician orders. The resident had orders for Insulin Lispro at breakfast, midday, and supper, with instructions to hold the dose if meal intake was less than 25%, but staff administered the insulin after the resident refused meals on multiple occasions. An RN later acknowledged the order was not followed.
A resident at risk for PI with a history of healed pressure injuries did not receive consistent ordered offloading and repositioning. Surveyors repeatedly observed the resident in bed with heels touching the mattress while wearing incorrectly sized heel boots, and the blanket was left on the toes instead of over the foot guard. Staff also failed to apply an ordered bordered foam dressing to the right buttock until the surveyor identified the omission, and the DON and RN later confirmed the heel boots were the wrong size and the right heel had an area of concern.
Improper Transfer Technique and Failure to Follow Care Plan: Staff transferred a resident with dementia, Huntington’s disease, and an above-the-knee amputation without following the care plan for assist of 2 with a gait belt. A CNA and another CNA performed stand-pivot transfers from a wheelchair to bed without a gait belt, and the wheelchair was not locked during one transfer. The CNA stated the gait belt was not used because the resident was on anticoagulants, but the care plan did not say that, and an RN confirmed the resident should have been transferred with a gait belt and 2-person assist.
Respiratory Treatment Given Without Required Assessment: A resident with COPD, acute respiratory failure with hypoxia, and other complex diagnoses received scheduled Albuterol and Budesonide nebulizer treatments with vest therapy, but a nurse tech did not assess lung sounds or obtain pulse oximetry before, between, or after the treatments. The nurse tech also stated the nebulizer set-up would be cleaned later and rinsed before the next treatment, while an LPN and the DON stated lung sounds should be assessed before nebulizer treatment.
An LPN was observed during medication pass with repeated missed hand hygiene before and after resident contact and before preparing medications. Staff also failed to use required PPE during high-contact care for a resident on EBP, and multiple CNAs were observed with improper glove changes, missed hand hygiene, and contaminated equipment handling during toileting, catheter care, and transfer care.
A resident with multiple medical conditions alleged that a CNA physically abused them, but the incident was not reported to the administrator or law enforcement within the required two-hour timeframe. The CNA continued working for several hours after the incident, and the initial report to the state agency was delayed by several days, in violation of facility policy and federal requirements.
The facility failed to maintain sanitary conditions for food storage and service, affecting 32 residents. Observations included undated opened food items, improper storage of dry goods, and missing temperature documentation for food and dishwasher operations. These issues indicate non-compliance with FDA Food Code 2022 standards.
The facility failed to implement a restorative program for residents with limited range of motion (ROM), despite their medical conditions requiring such care. Observations and interviews confirmed that residents with conditions like cognitive impairment, cerebral infarction, and morbid obesity did not receive necessary therapy or restorative services. Staff, including the NHA, acknowledged the absence of a structured program to address these needs.
The facility did not adhere to its policy for screening employees for abuse, neglect, or exploitation history. A RN was hired without a timely DOJ response or IBIS letter, and background checks for a housekeeper and a CNA were outdated. The BOM and CNHA confirmed the oversight, acknowledging the checks were overdue.
A facility failed to conduct an accurate MDS assessment for a resident with Alzheimer's, dementia, and congestive heart failure. The MDS incorrectly indicated a wound infection diagnosis, which was acknowledged by the NHA as a coding error on multiple assessments. Corrections were later provided by an LPN.
The facility was found deficient in infection prevention and control due to inadequate hand hygiene practices. A CNA failed to perform hand hygiene after removing gloves during resident care, and the DON did not perform hand hygiene between glove changes during a dressing change for a resident with severe medical conditions. Both staff members cited nervousness as a factor in their lapses.
Food Storage and Sanitizer Monitoring Deficiencies
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the kitchen. During observation, a scoop was left inside the flour storage bin, and another scoop was observed left in the sugar bin when the bins were opened for surveyor observation. The dietary manager stated that scoops are supposed to be cleaned and kept by the bins, and that used scoops should go back through the dishwasher, but the observed scoop remained in the bin. Facility policy on dry food storage stated that working containers holding dry food or ingredients removed from original packages are to be identified with the common name of the food, and that staff receive training on proper dry food storage. The facility also did not ensure that the red bucket sanitizing solution was monitored and documented as required. The facility log for litmus testing of the bucket system showed multiple missed opportunities to test sanitizer concentration and multiple entries that were out of range, with unclear follow-up. Surveyor review found missed tests in April, June, and July 2025, along with numerous out-of-range PPM readings in April, May, June, and July. The dietary manager stated staff complete the log at every meal, but no policy was produced during the survey, and when asked about scribbled-out entries, the dietary manager stated, "I don't know what is going on there. I guess it was a missed test."
Missing Out-of-State Background Check for RN
Penalty
Summary
The facility did not ensure that 1 of 8 employees was screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before employment. Surveyor review found that Registered Nurse H completed a Background Information Disclosure (BID) on 07/08/24 and indicated having lived in Minnesota within the last 3 years, but the facility did not run a Minnesota background check. The BID was run through the Wisconsin database on 08/27/24, but the Minnesota check was not completed. During interview on 07/29/25 at 10:01 AM, the Business Office Manager stated that the missing Minnesota background check was missed and that corporate usually notifies the facility when an out-of-state background check is needed. The Business Office Manager also stated that RN H did not have the background complete and that it was not completed prior to surveyors' arrival to the facility for the survey.
Incomplete Sleep Hygiene Care Planning
Penalty
Summary
The facility did not develop and implement a comprehensive care plan for two sampled residents to address identified sleep needs after melatonin was prescribed for insomnia. One resident was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, anxiety, aphasia, right-sided hemiplegia, narcolepsy, and atrial fibrillation, and had a physician order on 03/01/25 for melatonin 5 mg by mouth at bedtime for insomnia. A sleep assessment completed on 06/26/25 documented that the resident slept an average of 7-8 hours, had a goal of 8 hours, and should try to avoid excess fluid intake, but the care plan did not include a sleep hygiene plan with non-pharmacological interventions. Another resident was admitted with diagnoses including encephalopathy, weakness, late-onset Alzheimer's disease, depression, anxiety disorder, and chronic kidney disease stage 3b, and had physician orders for melatonin on 07/03/23 and 09/29/23 for insomnia. On 07/30/25, the Quality Consultant RN stated there was not a sleep care plan developed for either resident and that a care plan was entered now.
Insulin Given Despite Refused Meals
Penalty
Summary
Facility staff did not ensure that a resident with type 2 diabetes mellitus, vascular dementia, and adult failure to thrive received insulin in accordance with physician orders. The resident, whose cognition was moderately impaired and who required staff supervision when eating, had orders for Insulin Lispro 8 units at breakfast and midday and 6 units at supper, with instructions to hold the dose if meal intake was less than 25%. Record review showed that on three separate occasions the resident refused a meal, yet Insulin Lispro was still administered: 8 units after breakfast was refused, 8 units after lunch was refused, and 6 units after supper was refused. During interview, the Quality Consultant RN acknowledged that the physician order was not followed and stated the order would be clarified with the physician.
Failure to Consistently Offload Heels and Follow Pressure Injury Care Plan
Penalty
Summary
The facility failed to provide consistent pressure injury prevention care for a resident who was at risk for pressure injuries and had a history of multiple healed stage 2 and unstageable pressure injuries. The resident was dependent on two people for bed mobility, rolling, transfers, toileting, and other care needs, and the care plan directed staff to reposition every hour, float the right heel off the bed, and use pillows for pressure relief on the buttock. Physician orders also directed use of heel protection boots, offloading after meals, and a bordered foam dressing to the right buttock. During survey observations, the resident was repeatedly found lying in bed with the heels touching the mattress while wearing NyOrtho Zero-G boots, and the blanket was lying on top of the toes instead of being draped over the foot guard. The surveyor did not observe the heels floated to relieve pressure during multiple observations. The resident was also observed after breakfast and while lying on the back in bed without the heels offloaded as directed. A CNA later confirmed the heels were touching the bed surface through the boots and stated the resident’s blanket should not be lying on the toes. The survey also found that the resident’s right buttock dressing order was not being followed. An LPN stated staff had not reported that the dressing was needed and had not placed the Meplix bordered foam on the right buttock. When the surveyor and LPN assessed the area, the right buttock was slightly red and the LPN then applied the dressing. In addition, the resident’s NyOrtho Zero-G boots were found to be the wrong size; the tag showed a large bariatric size, but the calf measured 12 inches in circumference, and the DON and RN later stated the resident should have been wearing a medium size instead of a large size. The DON also stated staff remained responsible for the resident’s care even when nursing students were providing care, and the RN later documented the right heel as an area of concern with bogginess and peeling skin.
Improper Transfer Technique and Failure to Follow Care Plan
Penalty
Summary
The facility did not ensure the resident’s environment remained as free of accident hazards as possible because staff did not follow the resident’s transfer precautions and supervision needs. R2 was admitted with diagnoses including right above-the-knee amputation, unspecified dementia, Huntington’s disease, chorea, neurocognitive disorder, heart valve replacement, and depression. The MDS dated 07/17/25 identified that R2 required partial to moderate assistance with transferring and had a lower impairment to one side. The care plan directed assist of 2 for transfers with a gait belt and noted that a prosthetic leg was not appropriate, with locomotion in a wheelchair. During observation, CNA D and CNA F transferred R2 from the wheelchair to the bed without using a gait belt. Surveyor observed CNA D hug R2, instruct R2 to hug back, stand R2, and pivot R2 on one leg to the bed, then sit R2 on the edge of the bed and boost R2 further into bed. The right side of the wheelchair was not locked during the transfer. Later, CNA D and CNA F again used a stand-pivot transfer to place R2 in bed without a gait belt. When interviewed, CNA D stated the care plan did not use a gait belt because R2 was on anticoagulants, but the care plan did not contain that instruction. Regional Corporate RN G confirmed R2’s transfer plan was assist of 2 with a gait belt and stated CNAs should have used the gait belt and assist of 2 because R2 was at risk for falls and could be hard to transfer due to flailing.
Respiratory Treatment Given Without Required Assessment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for one resident who was admitted with diagnoses including tetralogy of Fallot, COPD, acute respiratory failure with hypoxia, macrocephaly, disturbances of salivary secretion, anxiety disorder, and persistent mood affective disorder. The resident's MDS indicated poor hearing, no speech, inability to understand and rarely be understood, inability to make decisions due to cognitive skills, and dependence for mobility, transfers, and all cares. The physician ordered Albuterol Sulfate 2.5 mg/3 ml and Budesonide 0.25 mg/2 ml inhalation twice daily, along with vest therapy for 15 minutes during nebulizer treatments, and the care plan directed staff to monitor breathing, neuro status, and vitals and to prevent airway obstruction by elevating the head of the bed 30 degrees. During observation, a nurse tech administered the resident's Albuterol nebulizer treatment followed by the Budesonide nebulizer treatment while also providing tube feeding care. The nurse tech assembled the nebulizer equipment, placed the Albuterol solution in the cup, attached the mask, applied it to the resident, and started the treatment, then started the second nebulizer treatment after the first was completed. The vest therapy ended at the 15-minute mark and the second nebulizer treatment was completed shortly after. The nurse tech removed the mask and vest and stated the equipment would be cleaned later and rinsed before the resident's next nebulizer treatment, noting that set-ups are cleaned once per shift. The nurse tech did not assess lung sounds or obtain pulse oximetry before, between, or after the nebulizer treatments. An LPN and the DON both stated that lung sounds should be assessed before nebulizer treatment, and the DON stated nebulizer supplies are cleaned once a shift and at least rinsed in between uses.
Infection Control Lapses During Medication Pass and Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. During medication administration, an LPN was observed over a 2-hour period with repeated missed hand hygiene opportunities for four residents. The LPN handled garbage, prepared medications, entered and exited resident rooms, and administered medications without performing hand hygiene before or after resident contact or before preparing medications. The LPN later stated that hand hygiene should occur anytime staff touch patients and that alcohol gel bothered her, so she used wipes. The DON stated hand hygiene should occur anytime there is interaction with patients, including before and after taking blood pressures, preparing and passing medications, and assisting residents with eating. A resident on enhanced barrier precautions due to tube feedings was observed receiving tube feeding administration from a nurse tech who did not wear a gown. The resident had diagnoses including tetralogy of Fallot, COPD, acute respiratory failure with hypoxia, macrocephaly, disturbances of salivary secretion, anxiety disorder, and persistent mood affective disorder. The facility policy stated that enhanced barrier precautions require gown and glove use during high-contact resident care activities, including device care such as feeding tubes. The DON confirmed that tube feeding residents are on enhanced barrier precautions and that the nurse tech should have had a gown on. Another resident on enhanced barrier precautions was observed during toileting and transfer care with multiple PPE and hand hygiene issues. Two CNAs transferred the resident with an EZ-Stand, and one CNA later cleaned under the resident’s fingernails in the bathroom without a gown, despite stating she knew she should have had one on. During toileting and catheter care, contaminated gloves were used while handling the resident and equipment, gloves were changed without observed hand sanitization, and the EZ-Stand sling was not observed being removed or sanitized before use with another resident. A nursing student was also observed taking the contaminated EZ-Stand into another resident’s room without the sling being removed or sanitized. In a separate observation, a CNA providing personal care to another resident removed gloves, washed hands, reapplied gloves, then later removed gloves again and changed to clean gloves without sanitizing hands between glove changes while completing peri-care and brief changes.
Failure to Timely Report Alleged Physical Abuse and Notify Authorities
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of an allegation of physical abuse in accordance with section 1150B of the Act. Specifically, when a resident with multiple diagnoses, including athetoid cerebral palsy, dementia, and anxiety disorder, alleged that a certified nursing assistant (CNA) had slammed them against the wall, the incident was not reported immediately, or within the required two-hour timeframe, to the administrator and local law enforcement. The facility's policy requires immediate safeguarding of the resident and prompt reporting of all alleged violations to the administrator, who is then responsible for notifying the state agency and law enforcement within two hours of forming a suspicion. In this case, the administrator could not recall the exact time the allegation was reported but confirmed that the CNA was not removed from duty until later in the evening, several hours after the incident occurred. The initial report to the state agency was sent ten days after the incident, and law enforcement was not contacted as required. The facility's reported incident documentation did not specify when the administrator was notified, and the administrator acknowledged that the reporting was not timely and could not explain the delay.
Food Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and served under sanitary conditions, which had the potential to affect 32 residents. During an initial tour of the kitchen, a surveyor observed several deficiencies, including an open package of frozen chicken and fish fillets without a date, and a gallon of milk opened and not dated in the refrigerator. Additionally, a 50lb box of Idaho potatoes was found sitting on the floor in the dry storage area, along with 'Quick Oats' in a five-gallon pail with about an inch of oats at the bottom. These observations indicate a lack of adherence to the FDA Food Code 2022, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with a date and stored at least 6 inches above the floor. Further investigation revealed missing temperature documentation for food items and the dishwasher. The surveyor noted missing temperatures on the PM shift for several days in May, as well as missing supper food temperatures in March and April. Additionally, there were missing records for temperature/chlorine Parts Per Million (PPM) in May, and the facility was unable to locate March documentation. These lapses in documentation suggest a failure to maintain proper records for food safety, as required by the FDA Food Code 2022, which mandates that time/temperature control for safety food be maintained at specific temperatures to prevent contamination.
Lack of Restorative Program for Residents with Limited ROM
Penalty
Summary
The facility failed to implement a restorative program to maintain or improve the range of motion (ROM) for five residents with limited mobility. These residents, identified as having various medical conditions such as moderate cognitive impairment, cerebral infarction, above-the-knee amputation, Alzheimer's/dementia, and morbid obesity, did not receive therapy or restorative nursing services. Despite assessments indicating functional limitations in ROM, the facility did not have a restorative program in place for these residents, as confirmed by interviews with the Nursing Home Administrator (NHA) and other staff members. Observations and interviews revealed that the residents required assistance with activities of daily living (ADLs) and mobility, yet no structured restorative activities were provided. For instance, one resident needed repositioning every two hours, while another required help with washing and catheter care. The lack of a restorative program was consistently acknowledged by the NHA and other staff, indicating a systemic issue in addressing the residents' ROM needs. This deficiency was noted during the surveyor's review and interviews, highlighting the facility's failure to provide necessary restorative care to maintain or improve the residents' functional abilities.
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to implement its policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property. This deficiency was identified during a review of caregiver background checks for eight randomly selected staff members. Specifically, a Registered Nurse (RN) was hired without a completed Department of Justice (DOJ) response or Integrated Background Information System (IBIS) letter at the time of hire, which was contrary to the facility's policy. The Business Office Manager (BOM) and Corporate Nursing Home Administrator (CNHA) both acknowledged that the background check was overdue by 29 days, as it was not conducted within the 60-day period required by law. Additionally, the surveyor found that the background checks for a Housekeeper and a Certified Nursing Assistant were outdated, with the last checks conducted over four years ago. The BOM confirmed that these checks appeared to be overdue. The Nursing Home Administrator (NHA) acknowledged the issue of late caregiver background checks for the three employees and identified it as a problem within the facility's processes.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to conduct a comprehensive and accurate assessment for one resident, identified as R5, during the Minimum Data Set (MDS) assessments. R5 was admitted with a Brief Interview of Mental Status (BIMS) score indicating moderately impaired cognition and had diagnoses of Alzheimer's, dementia, and congestive heart failure. The MDS dated incorrectly indicated that R5 had an active diagnosis of a wound infection under the major disease category. Upon inquiry by the surveyor, the Nursing Home Administrator (NHA) acknowledged that the MDS was incorrectly coded on multiple occasions, including the quarterly and annual assessments. The Licensed Practical Nurse (LPN) later provided corrections for the MDS, indicating that there was no major wound infection as previously recorded.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during resident care, leading to a deficiency in infection prevention and control. During an observation, a Certified Nursing Assistant (CNA) was seen performing peri care for a resident who was incontinent of bowel. After cleaning the resident, the CNA disposed of dirty items and removed gloves but did not perform hand hygiene before continuing care with bare hands. The CNA admitted to not having enough gloves in the room and feeling too nervous to stop and retrieve more, which led to the oversight. In another instance, the Director of Nursing (DON) was observed performing a dressing change on a resident with severe medical conditions, including diabetes and osteomyelitis. The DON initially followed proper hand hygiene and PPE protocols but failed to perform hand hygiene between glove changes during the procedure. When questioned, the DON acknowledged the mistake, attributing it to nervousness. These incidents highlight lapses in adherence to the facility's infection prevention and control policy, which requires hand hygiene before and after glove use.
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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 Amery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Age Manor | 0.2 mi | ★★★★★ | 2 | 0 |
| Dove Healthcare - St Croix Falls | 14.9 mi | ★★★★★ | 21 | 0 |
| St Croix Health Center | 15.2 mi | ★★★★★ | 10 | 0 |
| Deerfield Care Center, Llc | 15.7 mi | ★★★★★ | 4 | 0 |
| Christian Community Home Of Osceola, Inc | 16.1 mi | ★★★★★ | 4 | 0 |
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