Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Willows Center during CMS and state inspections, most recent first.
Surveyors found that PTAC units in three resident rooms were not maintained in a clean and safe condition, with debris and a black-like substance observed in the upper vents of multiple units during a complaint survey. The facility Administrator confirmed these environmental issues, which affected the residents’ right to a safe, clean, comfortable, and homelike environment.
Improper disposal of garbage and refuse was observed when one dumpster was overflowing with garbage bags and could not close properly, while the other dumpster’s sliding doors were not fully closed. The Director of Dining acknowledged that dumpster lids should be closed when not in use and that they were not.
The facility did not submit required five-day follow-up documentation for investigations into suspected abuse and failed to report results to all necessary state agencies. For two residents, investigation files lacked timely follow-up, witness statements, and evidence of proper notification, as confirmed by the administrator.
Multiple allegations of abuse, neglect, and mistreatment were not thoroughly investigated, with missing or incomplete documentation, lack of timely reporting to authorities, and insufficient interviews of staff and residents. Investigations were often inconclusive due to conflicting statements, and required follow-up actions and reports were not consistently completed or documented.
Three residents did not receive scheduled showers or adequate assistance with ADLs as documented in their care plans, with staff and resident interviews confirming missed care and lack of refusals. The DON verified that documentation did not support that showers were provided as scheduled.
Surveyors found that the facility did not serve food and beverages at safe and appetizing temperatures, with milk on a beverage cart measured above FDA guidelines and food tray temperatures not documented. A resident reported that meal preferences were not updated, food was often cold, and meal presentation was poor, with items mixed together on the plate. The Food Service Director confirmed these issues during the survey.
Surveyors identified multiple failures in food storage, preparation, and sanitation, including soiled food delivery carts, missing temperature logs, improperly stored and undated food items, dirty kitchen equipment, and incomplete documentation of sanitizer levels. Additional issues included outdated food, improper trash can use, and food containers placed directly on the floor. Staff confirmed these deficiencies and acknowledged lapses in following proper food safety and sanitation procedures.
Incomplete and non-person-centered care plans were found for two residents. One resident’s care plan had multiple blank ADL sections, with no measurable goals or timeframes, and the DON acknowledged it was not completed within the required timeframe. Another resident’s care plan was outdated, vague, and not individualized, using generic language and missing resident-specific details and preferences; the Administrator stated care plans should be resident specific and updated regularly.
The facility failed to follow physician orders and required assessment documentation for multiple residents. One resident with chest pain did not receive ordered q4h VS monitoring, another resident’s PRN hydralazine parameters were not followed on several occasions, and a resident with unwitnessed falls had no documented neuro checks after the falls. The facility also lacked hospice admission records, the hospice care plan, and the expected hospice medication documentation for a resident receiving hospice services.
A resident receiving dialysis through a Permacath and with an AV fistula had orders to monitor the fistula for bleeding, edema, infection, bruit, and thrill, but the record contained no documentation that the Permacath site was monitored. The resident stated the catheter was in the right chest, and an RN confirmed there was no documentation of Permacath site monitoring despite facility policies requiring nursing evaluation and documentation of vascular access sites after dialysis.
Unlabeled, undated, and expired medications were found in the Main Medication Room and 100 Hall medication storage area. Surveyors observed opened vaccines, an opened Vancomycin container, expired ear wax removal items, and expired infusion tubing, and an RN stated that medications should be labeled with a name and open date as soon as they are opened.
Meal Preferences Not Updated or Followed: A resident reported that meal preferences had not been updated and that a manager had not met with her despite repeated requests. At lunch, the resident was served a turkeyburger with baked beans on the plate, and the beans ran under the bun. Interviews and record review also showed other residents had not had recent preference updates, and one resident with no capacity had no preference form completed.
Incomplete and inaccurate resident records were identified for three residents. One resident’s care plan listed the wrong name, another resident with dialysis access had BP documentation that showed arm readings despite an order to avoid both arms and use a thigh cuff, and a third resident’s physician capacity form was left incomplete even though diagnoses and cognitive impairment details were entered.
The facility failed to hold required quarterly QAA meetings and did not have the required members present or signed in for the meetings. Review of QAA records showed no meeting was conducted in the first or third quarter of 2025, and the Administrator confirmed the missing sign-ins and lack of documentation. This affected all residents in the facility.
Infection prevention and control failures were identified when staff did not follow enhanced barrier precautions and did not maintain sanitary practices during resident care. An RN and NA performed a wound dressing change for a resident with a chronic sacral pressure ulcer without gowns despite an EBP sign being posted, while two other residents with an indwelling urinary catheter and a dialysis catheter lacked required EBP signage and related orders in the chart.
A resident receiving hospice care developed multiple pressure ulcers, but the facility did not document timely assessments or ensure that wound care orders were included in the TAR or MAR. The DON confirmed that full assessments and evidence of treatment were lacking for the pressure ulcers and related interventions.
A facility failed to ensure two residents received a dignified dining experience. One resident was served after other tables were served, and staff said the tray was still in the kitchen. Another resident was fed while in bed by an RN who was standing beside the resident, despite a chair being available and the facility’s feeding procedure directing staff to sit at eye level.
A resident remained in the facility after Medicare skilled coverage ended, and although a NOMNC was issued, there was no evidence that the required SNF ABN was ever provided. During interview, the bookkeeper checked the EMR, business office files, and the Administrator's office, and the BOM confirmed that a SNF ABN had not been issued.
A resident room had unfinished drywall compound on the wall beside the bathroom and above the bed, along with multiple areas of wall and paint damage. The room's HVAC filter was heavily soiled with dust and debris, and several other resident rooms also had dirty HVAC filters. The Administrator stated the room was not a homelike environment.
PASARR Not Updated for New Bipolar Diagnoses: The facility failed to complete a new PASARR for two residents after new Bipolar diagnoses were documented. One resident’s PASARR on file did not reflect the added Bipolar diagnosis, and the DOSS stated a new PASARR had not been completed. For another resident, a PASARR was completed before the Bipolar Disorder diagnosis was added, and the Social Service Director described relying on front office notification and updating PASARRs when diagnoses are added.
Care plans were not revised when treatment changed for two residents. One resident’s care plan still listed 24-hour one-on-one supervision after the order had ended, and another resident’s care plan did not match the dialysis-related order because it only restricted the left arm for BP/labs instead of both arms and did not include monitoring for the permacath site. The DON and an RN confirmed the discrepancies.
Missing Vision Assistive Devices: A resident reported that her $300 glasses were not returned after belongings were placed in storage on admission, and she had no glasses to use. The grievance log had no entry for the missing glasses, the grievance and inventory list could not be found, and staff gave conflicting accounts about when the loss was reported and whether magnifier/telescope glasses on the care plan were an actual need or only a recommendation.
Failure to Document and Assess Repeated Falls: A resident with multiple falls and fall-related injuries, including fractures, had incomplete and missing documentation for several fall events. The record lacked a note for one fall, omitted required risk management details such as predisposing factors, and showed only one fall risk assessment in the chart, which the DON confirmed was the only one documented.
A resident receiving hospice services had no hospice admission agreement, no hospice treatment plan, and no hospice medication set on the MAR. Only a LTC status form showing routine hospice was found, and the chart lacked documentation of comfort meds being administered or a clear hospice care outline.
A resident's MPOA was not informed of multiple medical appointments, resulting in the resident being transported and left at appointments without the MPOA's knowledge or presence. The facility acknowledged the communication lapse and confirmed that on one occasion, the resident was left at an appointment without staff present after the van driver became ill.
A resident's MPOA reported grievances about the facility transporting the resident to medical appointments without prior notification and leaving the resident at appointments without ensuring the MPOA was present. The complaints were not logged or investigated according to facility policy, and staff interviews confirmed the lack of documentation and follow-up.
A resident who required supervision during meals, as documented in their care plan and meal ticket, was served a meal without staff supervision. Staff failed to notice or follow the supervision order, and facility policy required that such residents be supervised or not served until assistance was available.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment by not maintaining Packaged Terminal Air Conditioners (PTACs) in good condition in three of five resident rooms reviewed. During a complaint survey with a facility census of 92, the State Agency (SA) observed debris in the upper vent of the PTAC unit in one resident room at approximately 9:15 a.m., debris and a black-like substance in the upper vent of the PTAC unit in a second resident room at approximately 9:18 a.m., and debris in the upper vent of the PTAC unit in a third resident room at approximately 12:30 p.m. The facility Administrator verified these findings during an interview at approximately 1:15 p.m., and the observations were acknowledged by the administrative staff upon exit later that afternoon. No additional clinical information, medical history, or specific conditions of the residents occupying these rooms were provided in the report.
Improperly Closed and Overflowing Dumpsters
Penalty
Summary
Garbage and refuse were not properly disposed of in the facility’s outside dumpsters. During observation, one of two dumpsters was overflowing with garbage bags so the lid could not properly close, and the other dumpster had sliding doors that were not completely closed. On 12/16/25 at 8:38 AM, two surveyors asked the Director of Dining to show them the trash dumpsters, and she acknowledged that the dumpster lids should be closed at all times when not in use and that they were not.
Failure to Timely Report and Document Investigation Results of Suspected Abuse
Penalty
Summary
The facility failed to report the results of investigations into suspected abuse, neglect, or theft within the required time frames to the state survey agency. For one resident, the file for a facility-reported incident was missing the required five-day follow-up documentation, despite the initial report being submitted on time. The file lacked evidence of any attempt to transmit the follow-up to the appropriate authorities, and the only documentation present included undated and unsigned statements, as well as non-disciplinary performance improvement plans with no noted corrections or follow-up actions. For another resident, an allegation of physical abuse was reported, but the investigation file did not contain documentation that the incident was reported to all required state agencies. There were no witness statements from staff or other residents, and no documented five-day follow-up was found. The administrator confirmed during interviews that there was no additional documentation or statements available regarding the incident.
Failure to Thoroughly Investigate and Document Alleged Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to appropriately respond to and thoroughly investigate multiple alleged violations related to abuse, neglect, exploitation, mistreatment, and injuries of unknown source. In several cases, allegations made by residents with intact cognitive status were not promptly or fully investigated, and required documentation such as witness statements, staff interviews, and resident interviews were missing or incomplete. For example, one resident reported being left soiled for four hours and not being assisted with meals, but the investigation lacked statements from staff or other residents who may have had knowledge of the incident. In another case, a resident alleged physical abuse and not receiving a meal tray, but there was no documentation that the incident was reported to all required state agencies, and no witness statements or follow-up documentation were present. Other incidents involved allegations of sexual abuse, neglect related to pressure ulcer development, and being left soiled for extended periods. In these cases, investigations were either delayed, lacked comprehensive interviews, or failed to document actions taken to determine the facts. For instance, a nursing assistant reported concerns about a resident developing a pressure sore, but the investigation concluded with an unsigned note attributing the issue to a communication and technology error, without addressing the specific failures in communication or documentation. In several cases, statements collected were undated, unsigned, or lacked sufficient detail, and follow-up actions such as call light audits were either not performed as described or not documented. Throughout the reviewed incidents, there were repeated failures to collect and document all relevant information, including statements from all staff and residents who may have had knowledge of the events, and to report allegations to the appropriate authorities in a timely manner. Investigations were often deemed inconclusive due to conflicting statements, but no secondary interviews or clarifications were attempted. In some cases, corrective actions or plans to prevent recurrence were not documented, and required follow-up reports were missing from the files. These deficiencies were confirmed by the administrator and DON during interviews, who acknowledged missing documentation and incomplete investigations.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide assistance with activities of daily living (ADLs), specifically showers and personal hygiene, to dependent residents as per their assessed needs and care plans. Three residents were found to have received fewer showers than scheduled, with documentation showing only one or two showers in a 30-day period, despite no refusals being recorded. Residents and their representatives reported that showers were not provided as ordered or preferred, and staff cited insufficient staffing as a reason for not providing showers. Observations confirmed poor personal hygiene, such as oily and uncombed hair, and interviews with the Director of Nursing verified the lack of documentation for scheduled showers. The deficiency was substantiated through resident and MPOA interviews, direct observation of residents' hygiene, and review of ADL documentation. In each case, the residents did not receive the number of showers outlined in their care plans, and there was no evidence that they refused care. The Director of Nursing confirmed the absence of documentation supporting that showers were provided as scheduled for the affected residents.
Failure to Serve Palatable and Properly Tempered Food and Beverages
Penalty
Summary
The facility failed to ensure that food and beverages were served at safe and appetizing temperatures, as well as in a palatable and attractive manner. During the survey, milk on a beverage cart was found to be at 54°F, which is above the FDA food code requirement of 41°F. The Director of Dining acknowledged this temperature violation. Additionally, when asked for food temperatures from the lunch menu, an employee stated that the cook was responsible for recording them on the production sheet, but the cook had not documented any temperatures. This deficiency was observed across four of five hallways tested for milk temperatures and in the food tray temperature for one meal tray tested. A resident reported dissatisfaction with the food, stating that meal preferences had not been updated despite requests made three months prior, and that food was often cold and not served as requested. The resident also noted that meals were sometimes served last, resulting in food running out, and that food items were mixed together on the plate. Observation of the resident's meal confirmed that baked beans were running onto the hamburger bun, and the Food Service Director agreed that the meal presentation was not appropriate. The Food Service Director also confirmed that the resident's meal preferences had not been updated.
Widespread Food Safety and Sanitation Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, distribution, and sanitation practices within the facility's kitchen and food service areas. Food delivery carts were found with food debris and dried substances on their shelves and exteriors. The kitchen walkthrough revealed missing dish machine temperature logs, soiled equipment such as the toaster, knife rack, can opener, and coffee maker, as well as improperly stored and undated food items including margarine, hamburger buns, cake mix, drink mixes, salad, ham, and sugar. Several food containers and packages were left open to air or lacked proper labeling and dating. Trash cans were found without lids, and some lacked liners. Food storage containers and sheet pans were placed directly on the floor, and the meat slicer and mixer bowl were left uncovered when not in use. Wet nesting of food storage container lids was also noted. Outdated food items were present in the walk-in cooler and nourishment room refrigerators, and the fan cover in the walk-in cooler, as well as ceiling vents in the kitchen, were dirty and rusty. Milk on a beverage cart was measured at a temperature above the FDA food code requirement. Further observations included improperly closed dumpster lids, a soiled fan in the dish room, and clean trays placed on the hand-washing sink. Employees were found to be documenting incorrect sanitizer PPM values on the dish machine log, and the three-compartment sink log was incomplete for certain meals. Trash cans in the dish room and near the steam table were missing lids when not in use. Staff interviews confirmed these deficiencies, and staff acknowledged that proper procedures were not followed regarding food safety, sanitation, and documentation.
Incomplete and Non-Person-Centered Care Plans
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for Resident #39 that included measurable objectives and timeframes to meet medical and nursing needs. The electronic record review showed a care plan initiated on 12/08/25 with multiple blank sections in the focus, goal, and intervention areas for assistance with ADLs, including bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. During interview, the DON acknowledged the care plan had numerous areas left blank and was not person-centered, and stated the initial care plan should have been completed within 72 hours of admission; it remained incomplete as of 12/22/25 at 9:50 AM. For Resident #38, the care plan on file was dated 1/18/23 with a revision date of 11/14/25, but no updates were made beyond acknowledging the revision. The plan was not specific to the resident and did not include resident-specific details such as name, age, or gender, using vague terms such as "resident" and "monitor for decline." On page four, the care plan contained generic statements such as "While in the facility, resident/patient states that is important that s/he has the opportunity to" and "Resident will plan and choose to engage in preferred activities," but the staff did not correct the gender reference or document any choices or preferences. The Administrator stated that all care plans should be resident specific and updated on a regular basis.
Failure to Follow Orders and Document Required Assessments
Penalty
Summary
The facility failed to provide care in accordance with physician orders for Resident #3 after the resident reported chest pain and had a pulse of 104 beats per minute that was irregular. The on-call provider recommended vital signs every 4 hours for at least 48 hours to monitor heart rate, but no order for every-4-hour vital signs was entered. The record showed vital signs were obtained at 9:16 PM, 9:33 PM, 2:00 AM, 9:38 AM, and 10:50 AM, and the Director of Nursing confirmed there was no documentation of vital signs between 2:00 AM and 9:38 AM and that the resident’s vital signs were not obtained every 4 hours as ordered. For Resident #69, the physician ordered hydralazine 50 mg by mouth every 24 hours as needed for hypertension when systolic blood pressure was greater than 150 or diastolic blood pressure was greater than 90, and the medication was to be held on dialysis days. Review of the MAR showed the order was not followed on multiple dates. The resident did not receive hydralazine when blood pressures were 156/86, 155/71, and 165/77, and the resident received hydralazine on several dialysis days when the medication was ordered to be held. RN #54 confirmed the physician’s order was not followed regarding the hydralazine administration. For Resident #96, the facility policy required neurological checks after an unwitnessed fall or a fall with head injury, but the resident’s records contained no documentation of neurological checks after two falls on 10/03/24 and no documentation after a fall on 11/05/24. The 10/03/24 events included the resident found on the floor beside the bed, assisted back to bed, and later found on the floor again after trying to pick up a cup or water pitcher. The 11/05/24 fall involved the resident found on the floor with pain, a skin tear to the right upper arm, and a knot on the back of the head, yet no neurological checks were documented. For Resident #38, the facility also lacked hospice admission documentation, the hospice treatment plan, and the expected hospice medication set on the MAR; the only comfort-related orders in the chart were oxycodone and a DNR/selective treatments/no artificial nutrition order, and the social worker could not locate the hospice file or provide the hospice paperwork before the survey ended.
Dialysis Access Site Not Monitored
Penalty
Summary
The facility failed to provide dialysis services in accordance with professional standards of practice for Resident #69, who received dialysis through a Permacath dialysis catheter in the right chest and also had an arteriovenous fistula in the left arm that was not yet being used for dialysis. The resident stated he had both access sites, and the physician’s orders required monitoring of the arteriovenous fistula for bleeding, edema, and signs and symptoms of infection, as well as assessment for bruit and thrill. The record showed no orders to monitor the Permacath site or dressing for complications such as infection or bleeding, and the resident was not care planned for monitoring of the Permacath. The medical record contained no documentation that the Permacath site was monitored. The facility’s policies stated that the licensed nurse is responsible for evaluating and maintaining the external hemodialysis catheter site and that staff must monitor and document the vascular access site after dialysis for bleeding or other complications. On interview, the resident stated the Permacath was in place, and on interview RN #54 confirmed there was no documentation that the Permacath site was monitored.
Unlabeled, Undated, and Expired Medications Found in Medication Storage Areas
Penalty
Summary
Drugs and biologicals used in the facility were not stored and labeled in accordance with currently accepted professional principles. During an observation of the Main Medication Room, a refrigerator contained one box of Influenza Vaccine, one opened container of Hepatitis B Vaccine, and one opened container of Covid 19 Vaccine, all of which were not dated or labeled. In the 100 Hall Medication Room, surveyors observed one opened container of [NAME] that was expired, two ear wax removal items that were expired, one opened container of Vancomycin that was not dated or labeled, and one zynormef infusion tubing that was expired. RN #21 stated that medications should have been labeled with a name and open date as soon as they were opened by staff.
Meal Preferences Not Updated or Followed
Penalty
Summary
The facility failed to ensure resident meal preferences were obtained, updated, and followed according to policy and best practice. During the annual survey, Resident #58 stated that the food was terrible and that meal preferences had not been updated, adding that she had asked the manager almost three months earlier to come speak with her. At lunch, Resident #58 was served a turkeyburger with lettuce, tomato, and baked beans on the plate; the resident stated this was what she ordered but said she wished the beans had been placed in a bowl because they were running under the hamburger bun. The Food Service Director later confirmed that the baked beans were running into the bun. Record review and interviews also showed that meal preferences had not been updated for other residents. Resident #37 reported that no one had met with her for awhile, and Resident #31 reported that no one had met with him; the record noted no capacity for Resident #31 and that no preference form had been completed. Resident #37 had an initial meal preference completed on 10/19/21, with updates on 03/25/22 and 04/02/24, while Resident #58 had an initial preference completed on 03/21/25. The Food Service Director stated that she had not updated Resident #58’s meal preferences, and the District Manager stated that best practice is to meet with the resident initially and follow up if concerns, requests, or significant changes occur; if a resident lacks capacity, staff still attempt to interview for preferences and, if unable, social services are made aware and may reach out to family.
Incomplete and inaccurate resident medical records
Penalty
Summary
Complete and accurate medical records were not maintained for three residents reviewed. For one resident, the care plan contained the wrong name, and the administrator confirmed the error during the survey interview. For another resident with an AV dialysis fistula in the left arm and a Permacath dialysis catheter in the right chest, the physician ordered no blood pressures or needle sticks in either arm and to use a thigh cuff for blood pressure; however, the resident stated staff used the leg for blood pressures, while the record showed multiple vital sign entries documenting blood pressure readings taken from the left or right arm. An RN confirmed that the documentation was incorrect and that the readings should have indicated the leg was used. For a third resident, the medical record contained a Physician Determination of Capacity form signed by the physician that was not fully completed. The form left blank the section requiring the physician to indicate whether the resident had or lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions, even though diagnoses and details of incapacitation were checked, including cognitive loss and inability to understand or make medical decisions. A prior capacity form for the resident had indicated the resident did not have capacity, and the DON confirmed the later form was incomplete.
QAA Committee Failed to Meet Quarterly and Lacked Required Attendance
Penalty
Summary
The facility failed to have required quarterly Quality Assessment and Assurance (QAA) meetings and failed to have the required members present or sign in for the QAA meetings. Review of the facility's QAA Meeting Agenda and Minutes showed no meeting was conducted in the first quarter or the third quarter of 2025. During an interview on 12/22/25 at 11:30 AM, the Administrator verified that the required members did not sign in for the quarterly QAA meetings and that there was no documentation of QAA meetings in the first and third quarter. The report states this affected all residents residing at the facility, with a census of 93.
Infection Prevention and Control Program Deficiencies
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 infections. The deficiency involved failure to follow accepted standards of practice related to enhanced barrier precautions, as well as failure to perform hand hygiene between residents while giving residents ice and failure to keep the ice cart clean and sanitary. These were random opportunities for discovery and were identified as having the potential to affect more than a limited number of residents. Resident #5 had a sacral pressure ulcer that had been present since August 2025 and had a dressing change order for cleansing, applying Z-Guard, and covering with a bordered gauze dressing. Although an enhanced barrier precautions sign was posted on the room door, RN #65 and NA #13 performed the dressing change on 12/17/25 without wearing gowns, even though the resident’s wound met the facility’s definition of a chronic wound and the resident did not have an enhanced barrier precautions order. Resident #3 had an order for enhanced barrier precautions, an indwelling urinary catheter, and a stage III pressure ulcer to the left heel, but no sign was posted on the door or outside the room. Resident #69 reported receiving dialysis through a Permacath dialysis catheter in the right chest, but there was no enhanced barrier precautions sign posted and no order for enhanced barrier precautions in the chart, although RN #54 confirmed the resident should have been on enhanced barrier precautions due to the dialysis catheter.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to assess and treat pressure ulcers according to accepted standards of care for a resident who was admitted and receiving hospice services. Although a nurse practitioner identified a stage II pressure ulcer on the sacrum and provided specific wound care orders, these orders were not included in the resident's Treatment Administration Records (TARs) or Medication Administration Records (MARs) for the relevant months. The first full assessment of the coccyx pressure ulcer was not documented until two days after its identification, and there was no evidence that the prescribed wound care was administered as ordered. Additionally, a subsequent skin check identified a new deep tissue injury to the right heel and a blister to the left scapula, with new treatment orders written for these conditions. However, these orders were also not reflected in the resident's TAR or MAR, and there was no documentation that the treatments, including the application of heel boots, were carried out. The Director of Nursing confirmed the lack of timely assessment and documentation, as well as the absence of evidence that physician orders were followed.
Dignified Dining and Feeding Practices Not Followed
Penalty
Summary
The facility failed to ensure two residents received a dignified dining experience. For Resident #95, during the lunch meal observation, another resident was served at the table while Resident #95 was not served until 10 minutes later, and staff were observed serving other tables before serving Resident #95; when interviewed, Staff #23 stated, "His tray must still be in the kitchen." For Resident #3, the facility procedure for feeding a patient/resident instructed staff to sit in a chair at eye level when feeding a resident, but RN #65 was observed feeding Resident #3 in his room while standing beside the resident, who was in bed, despite a chair being available at the bedside. RN #65 acknowledged she should have been seated to feed the resident.
Failure to Issue SNF ABN for Resident After Medicare Skilled Coverage Ended
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to 1 of 3 residents reviewed for the facility's beneficiary protection notification practice during an annual survey. Resident #72 remained in the facility after 07/10/25, the last day of Medicare Skilled Coverage. The NOMNC was issued on 07/08/25, but there was no evidence that the SNF ABN was ever issued. During an interview on 12/18/25 at 11:25 AM, Bookkeeper #72 stated, "I don't think so. I can check." After searching the electronic medical record, business office files, and the Administrator's office, she returned with the Business Office Manager, and the Business Office reported that a SNF ABN had not been issued.
Poor Room Condition and Dirty HVAC Filters
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in one resident room observed during the survey. In that room, the wall beside Resident #52's bathroom had unfinished joint compound layers on top of drywall without paint covering it, measuring about 12 inches wide and extending approximately 2 1/2 feet up the wall. The ceiling above Resident #52's bed also had unfinished joint compound layers without paint, measuring about 15 inches long, and the rest of the room had multiple small areas of wall and paint damage measuring 1 to 2 inches each. The same room also had an air conditioner/heater filter soiled with about 3/8 inch of dust and debris. Additional resident rooms observed during the initial tour also had air conditioner/heater filters soiled with about 1/4 inch of dust and debris. An employee stated that the filters are cleaned once per month, and the Administrator observed the condition of Resident #52's room and stated it was not a homelike environment, noting that the room was not on the list for repair.
PASARR Not Updated for New Bipolar Diagnoses
Penalty
Summary
The facility failed to complete a new PASARR for residents with a newly evident or possible serious mental health disorder. For Resident #1, the record showed admission to the facility and a Bipolar diagnosis added on 06/27/25, but the only PASARR on file was dated 05/02/25 and did not reflect the Bipolar diagnosis. During interview on 12/17/25, the Director of Social Services stated that a new PASARR had not been completed to capture the resident’s Bipolar diagnosis. For Resident #6, the record review showed a PASARR completed on 09/02/25 and a Bipolar Disorder diagnosis documented on 10/17/25. During interview, the Social Service Director stated that front office staff usually let her know when a PASARR needs to be done or updated, that she checks the hospital PASARR and the facility PASARR upon admission to see if they match, and that after speaking with the front office, they normally do an update if there is an added diagnosis. The facility policy stated that Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if it is learned after admission that the PASARR was not completed or is incorrect, or if there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability, or a related condition.
Care plans not updated when treatment changed
Penalty
Summary
The facility failed to revise residents’ care plans when treatment changed. For Resident #52, a physician order for one-on-one supervision, 24 hours per day, began on 09/19/25 and was discontinued on 09/26/25, but the care plan printed on 12/16/25 still showed one-to-one supervision, 24 hours a day. During interview, the DON acknowledged that the one-on-one supervision ended in September 2025 and the care plan was not updated to reflect that. For Resident #69, physician orders included a 10/23/25 order stating no BP or needle sticks in the left or right arm due to dialysis access and to utilize a thigh cuff for BP. The resident stated he had a permacath dialysis catheter in the right side of his chest and a fistula in his left arm. The comprehensive care plan included a focus for impaired renal function and hemodialysis-related complications, with an intervention to not take BP or labs in the left arm and interventions to monitor the fistula site, but it did not include an intervention to monitor the permacath site. RN #54 confirmed the care plan incorrectly addressed only the left arm when the order stated not to use both arms, and confirmed the permacath site was not included in the care plan.
Missing Vision Assistive Devices
Penalty
Summary
The facility failed to ensure resident #59 received proper treatment and assistive devices to maintain vision abilities. Resident #59 reported that she had been in the facility for about two months and said that when she arrived, staff placed some of her belongings in storage. She stated that her $300 glasses had not been returned to her, that she had reported the missing glasses to the social worker, and that she currently had no glasses to use. A review of the grievance log on 12/16/2025 showed no grievances listed regarding the missing glasses for this resident. During interviews, the social worker stated that the facility had done a grievance and inventory process and needed to call and schedule an appointment, and also said there was a resident they called "sticky finger." The surveyor asked to see the resident's grievance and inventory list upon arrival, but the two social workers could not find them. The social worker reported she was unsure when she was notified of the missing glasses, but said a nurse aide told her not long after the resident arrived. Another social worker reported the resident's sister said the glasses had been missing since the resident was at the hospital before admission to the facility. When asked about magnifier/telescope glasses listed on the care plan, the social worker stated she had no knowledge of them and would look into it, and later reported that the magnifier/telescope glasses were just a recommendation.
Failure to Document and Assess Repeated Falls
Penalty
Summary
The facility failed to provide care and services within accepted standards of practice for falls for Resident #96. The resident had multiple falls documented in the record, including a fall on 10/01/24 when staff found the resident lying in the hallway in front of the room with the walker in front of him and a blanket on the floor; x-rays showed a fifth metatarsal fracture of the left foot. The resident also had a fall on 10/03/24 at 10:18 PM when staff found him lying on his left side on the floor beside his bed, assisted him back to bed with a Hoyer lift, and obtained vitals. The note stated the resident was trying to pick up a water pitcher from the floor, and x-rays of the thoracic/lumbar spine, right hip, and right ankle were ordered. The record also showed an earlier fall on 10/03/24 at 8:45 AM in a risk management report, but there was no corresponding progress note or change in condition note for that event. The risk management reports for the 10/03/24 falls did not have the sections for predisposing environmental, physiological, and situational factors completed. A physiatry note later referenced a fall on 10/27/25, but there was no documentation, assessment, or risk management report for that fall. A change in condition note and incident form for 11/05/24 described the resident on the floor with pain, a skin tear to the right upper arm, a knot on the back of the head, and a statement that he was reaching for the floor and landed on the floor; the resident had a fracture of the left tibia and fibula and required surgery. The DON confirmed that the 12/01/24 fall risk assessment was the only one in the record, that the morning fall on 10/03/24 was not recorded, that the therapist-reported fall was not recorded, and that no assessment or predisposing factor documentation was completed.
Hospice Documentation and Care Plan Not Available
Penalty
Summary
The facility failed to ensure quality and continuity of care were arranged for a resident receiving hospice services. Resident #38 was admitted with a fair prognosis under skilled nursing care and was immediately ordered hospice care for a terminal diagnosis for comfort. However, the facility had no record of a hospice admission agreement or any other documentation signed by the resident, the resident’s MPOA, or facility medical/social service staff, either electronically or in the hard copy binders used for residents. The only signed document on file was a long-term care status form indicating routine hospice care. The facility also had no record of the hospice treatment plan for Resident #38, and the expected medication set for a hospice patient was not on the MAR. The only comfort-related orders found in the E-chart were an oxycodone order placed on 11/4/25 and a DNR/selective treatments/no artificial means of nutrition order placed on 11/8/25. There was no indication in the MAR or paper documentation that the oxycodone was administered. During interview, the social worker stated hospice records were kept in a hard chart behind the nurses’ desk, but the file was not there when searched, and later identified only a long-term care status form uploaded in E-chart showing the hospice provider with no outline of care plan or actions to be taken.
Failure to Notify MPOA of Resident Medical Appointments
Penalty
Summary
The facility failed to inform the Medical Power of Attorney (MPOA) for a resident about scheduled medical appointments. According to interviews and record reviews, the MPOA was not notified of multiple neurology appointments, resulting in the resident being transported to these appointments without the MPOA's knowledge or presence. The MPOA only became aware of the appointments after being contacted by the doctor's office, which expected the MPOA to accompany the resident. This lack of communication occurred on at least three separate occasions. Additionally, documentation confirmed that the resident was transported to appointments with staff present, but on one occasion, the van driver became ill and left the resident at the appointment after notifying the facility. The facility's Corporate Coordinator acknowledged that the MPOA should have been notified and that the resident was left at the appointment without staff present. No information or statements were available regarding staff presence for one of the incidents.
Failure to Process and Investigate Resident Grievance Regarding Transportation
Penalty
Summary
The facility failed to process and investigate a grievance reported by a resident's MPOA regarding transportation to medical appointments. The MPOA stated that the resident was transported to appointments on multiple occasions without prior notification, and on two specific dates, the van driver dropped the resident off without ensuring the MPOA was present. The MPOA reported these concerns directly to the facility's Director of Nursing. However, a review of the facility's grievance log and records revealed that no grievances or complaints from the MPOA were logged for the relevant dates, and there was no completed grievance form or investigation documented. Further review of progress notes and appointment logs confirmed that the resident was transported to appointments on the dates in question, with staff present according to the notes. During staff interviews, the Corporate Coordinator acknowledged that the grievances were not logged and that the facility could not provide documentation of a completed investigation. Additionally, the van driver reported becoming ill and leaving the resident at an appointment on one occasion, but no information was available for the other incident. The facility's actions did not align with its grievance policy, which requires oversight, investigation, and written decisions for reported grievances.
Failure to Provide Required Mealtime Supervision
Penalty
Summary
A deficiency occurred when a resident who required supervision during mealtimes, as indicated in both the care plan and meal ticket, was served a meal without the necessary staff supervision. During a meal observation, an employee set up the resident's tray and drink but left the room, failing to remain and supervise the resident as required. Review of facility policy confirmed that staff are to sit with or supervise residents needing assistance during meals, or not deliver the tray until assistance is available. Staff interviews revealed that the employee who delivered the meal did not notice the supervision requirement on the meal ticket, and another staff member acknowledged that the resident should have been supervised during the meal.
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.
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What surveyors actually found near you
We read the 201 citations issued within 25 miles in the last 12 months — including the 4 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Parkersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkersburg Center | 1.4 mi | ★★★★★ | 34 | 1 |
| Eagle Pointe Healthcare Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Belpre Landing Nursing And Rehabilitation | 2.8 mi | ★★★★★ | 7 | 0 |
| Rockland Ridge Nursing & Rehabilitation Center | 3 mi | ★★★★★ | 3 | 0 |
| Worthington Healthcare Center | 3.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.