Inspection Reports for
Willard Care Center
400 WEST WALNUT LN, WILLARD, MO, 65781-9432
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
88% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify residents' families or responsible parties about changes in residents' health conditions, falls, and new physician orders for four residents.
Complaint Details
Complaint 2665069 regarding failure to notify families of resident health changes, falls, and new physician orders; substantiation status not explicitly stated.
Findings
The facility failed to ensure notification to the resident's family or responsible party of changes in condition for four residents, including falls and new medication orders. Staff did not document family notifications as required, despite multiple incidents and interviews confirming the lack of communication and documentation.
Deficiencies (1)
Failure to notify resident's family or responsible party of changes in health condition, falls, and new physician orders for four residents.
Report Facts
Residents affected: 4
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Interviewed regarding reporting changes in resident condition |
| CNA E | Certified Nurse Aide | Interviewed regarding reporting changes in resident condition |
| CMT C | Certified Medication Technician | Interviewed regarding notification of family about resident condition changes |
| LPN A | Licensed Practical Nurse | Interviewed regarding notification procedures for family and documentation |
| LPN B | Licensed Practical Nurse | Interviewed regarding notification and documentation of family contact |
| MDS Coordinator | Interviewed regarding notification procedures and staff responsibilities | |
| DON | Director of Nursing | Interviewed regarding facility policy and notification requirements |
| Administrator | Interviewed regarding notification responsibilities and documentation |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Oct 31, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors in the facility, specifically concerning the incorrect frequency of administration of ferrous sulfate to a resident over an extended period.
Complaint Details
Complaint 2651756 triggered the investigation. The complaint involved medication errors related to ferrous sulfate administration frequency. The report does not explicitly state substantiation status.
Findings
The facility failed to keep residents free from significant medication errors when staff administered ferrous sulfate daily instead of weekly as ordered for 82 days. The error was due to incorrect input of physician orders into the electronic Medication Administration Record (eMAR), and staff did not notice the discrepancy despite documentation showing daily administration instead of the prescribed weekly schedule.
Deficiencies (1)
Failure to ensure residents were free from significant medication errors related to incorrect frequency of ferrous sulfate administration.
Report Facts
Census: 56
Duration of medication error: 82
Medication dosage: 324
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication administration and order input responsibilities |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding medication administration and order input responsibilities |
| Registered Nurse C | Registered Nurse | Interviewed regarding medication order input and eMAR system |
| Director of Nursing | Director of Nursing | Interviewed regarding medication order input and verification |
| Administrator | Administrator | Interviewed regarding medication administration policies and staff responsibilities |
Inspection Report
Routine
Census: 37
Deficiencies: 3
Date: Mar 26, 2025
Visit Reason
Routine inspection of Willard Care Center to assess compliance with nutritional care and dietary supplement recommendations for residents.
Findings
The facility failed to ensure residents maintained acceptable nutritional status by not following up and implementing Registered Dietitian (RD) recommendations for supplementation and fortified foods for multiple residents. Several residents with wounds or underweight status did not receive recommended supplements timely. The Dietary Manager and Director of Nursing did not consistently implement or communicate RD recommendations, and documentation of diet orders and supplements was inconsistent.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to respond appropriately to all alleged violations.
Failed to provide enough food/fluids to maintain residents' health by not implementing RD recommendations for supplements and fortified foods for residents with wounds and underweight status.
Report Facts
Facility census: 37
Resident #1 weight: 248
Resident #2 weight: 73
Resident #3 weight: 90
Resident #4 weight: 106
Weight loss: 20
Supplement dosage: 30
Supplement dosage: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding diet order slips and supplement implementation | |
| Director of Nursing (DON) | Interviewed regarding failure to implement RD recommendations and follow-up | |
| Registered Dietitian (RD) | Provided dietary recommendations and monitored residents' nutritional status | |
| Housekeeping Supervisor | Assisted resident with meals and provided observations on supplement administration | |
| Certified Nurse Assistant (CNA) | Assisted residents with meals and observed supplement administration | |
| Administrator | Discussed RD recommendations and facility processes for implementation |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Feb 14, 2025
Visit Reason
The inspection was conducted due to allegations of possible abuse involving two residents (Resident #1 and Resident #2) that were not reported timely to the state survey agency.
Complaint Details
The complaint involved allegations of possible abuse between two residents that were not reported timely to the state agency and not fully investigated by the facility. The facility failed to hotline the incident and failed to complete investigations as required.
Findings
The facility failed to timely report allegations of possible abuse involving two residents to the state agency and failed to fully and timely investigate all allegations of possible abuse. Staff did not report or document the abuse allegations properly, and the facility did not complete investigations or notify the state as required.
Deficiencies (4)
Failed to timely report suspected abuse involving two residents to the state survey agency.
Failed to fully and timely investigate allegations of possible resident to resident abuse involving two residents.
Failed to provide an ongoing program of activities designed to meet the needs, interests, and well-being of residents, including failure to provide meaningful activities and care plan specific activity interests for residents.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to obtain wound care orders, ensure timely implementation of new wound care orders, timely physician notification, and complete documentation for one resident with stage 2 pressure ulcers.
Report Facts
Residents present: 39
Facility census: 31
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Witnessed resident to resident incident and reported to DON |
| DON | Director of Nursing | Responsible for reporting abuse and investigations |
| Administrator | Facility Administrator | Responsible for reporting abuse and ensuring investigations |
| Nurse Assistant A | Nurse Assistant | Reported resident agitation and abuse observations |
| Nurse Assistant C | Nurse Assistant | Reported resident to resident abuse observations |
| Certified Nurse Assistant G | Certified Nurse Assistant | Witnessed resident to resident incident |
| Certified Medication Technician D | Certified Medication Technician | Reported abuse observations |
| Licensed Practical Nurse E | Licensed Practical Nurse | Described abuse reporting procedures |
| MDS Coordinator/Care Plan Coordinator | Provided information on resident behaviors and abuse reporting | |
| Certified Nursing Assistant B | Certified Nursing Assistant | Reported resident complaints about lack of activities and wound care observations |
| Registered Nurse F | Registered Nurse | Described wound care procedures and responsibilities |
| Licensed Practical Nurse I | Licensed Practical Nurse | Described wound care procedures and responsibilities |
| Certified Medication Technician G | Certified Medication Technician | Reported wound care observations |
| Certified Nursing Assistant C | Certified Nursing Assistant | Reported wound care observations |
| Certified Nursing Assistant D | Certified Nursing Assistant | Reported wound care observations |
| Certified Nursing Assistant H | Certified Nursing Assistant | Reported resident boredom and lack of activities |
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 2
Date: Feb 14, 2025
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident activities and pressure ulcer care at Willard Care Center.
Findings
The facility failed to provide an ongoing program of activities meeting residents' needs and interests, and failed to provide care to all pressure ulcers per professional standards. Documentation and activity attendance were lacking, and wound care orders and treatments were incomplete or not documented.
Deficiencies (2)
F679 Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1). The facility failed to provide an ongoing program of activities designed to meet residents' needs and interests, and failed to document resident participation in activities.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii). The facility failed to provide care to all pressure ulcers per standards, including timely wound care orders, documentation, and physician notification for one resident with stage 2 pressure ulcers.
Report Facts
Facility census: 31
Sample size: 8
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Date: Dec 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's personal property, specifically a missing laptop.
Complaint Details
The complaint involved one resident (Resident #1) whose laptop was missing after a room move. The resident reported the missing laptop to staff, but the facility delayed reporting to the State Survey Agency until 12/05/24, beyond the required 24-hour timeframe. The facility also failed to notify local law enforcement. The investigation was incomplete, lacking documentation of interviews and police reports.
Findings
The facility failed to protect a resident from misappropriation of property when a laptop listed on the resident's inventory was missing. Additionally, the facility failed to report the allegation to the State Survey Agency within the required timeframe and did not notify local law enforcement. The investigation into the missing laptop was incomplete and lacked timely and thorough documentation.
Deficiencies (3)
Failed to protect resident from misappropriation of property when a laptop was missing.
Failed to timely report allegation of misappropriation to State Survey Agency and local law enforcement.
Failed to conduct a timely and thorough investigation into the allegation of misappropriation, including incomplete documentation and lack of staff and resident interviews.
Report Facts
Residents reviewed: 4
Facility census: 28
Date of resident admission: Aug 19, 2024
Date of resident MDS assessment: Nov 1, 2024
Date of resident inventory: Aug 20, 2024
Date of room move: Nov 20, 2024
Date of report to State Survey Agency: Dec 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Reported missing laptop to Administrator and assisted resident | |
| Business Office Manager | Reported allegations to Administrator and DHSS, interviewed during investigation | |
| Administrator | Responsible for reporting to DHSS, conducting investigation, and communicating with resident | |
| Director of Nursing | Participated in investigation of misappropriation allegations | |
| Certified Nursing Assistant A | CNA | Reported allegations to charge nurse, confirmed Administrator reported to DHSS |
| Certified Nursing Assistant B | CNA | Reported allegations to charge nurse, confirmed Administrator reported to DHSS |
| Certified Medication Technician C | CMT | Reported allegations to charge nurse, confirmed Administrator reported to DHSS |
| Registered Nurse D | RN | Confirmed reporting and investigation of allegations |
| MDS Coordinator | Provided information on reporting and investigation process |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 4
Date: Dec 20, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident property, specifically regarding a missing laptop belonging to Resident #1, and failure to report the allegation to the State Survey Agency and law enforcement within required timeframes.
Complaint Details
The complaint investigation was substantiated. The facility failed to protect Resident #1 from misappropriation of property and failed to report the allegation to the State Survey Agency and law enforcement within required timeframes. The investigation was incomplete and untimely.
Findings
The facility failed to protect residents from misappropriation of property and did not report the allegation of misappropriation to the State Survey Agency and law enforcement within the required timeframes. The facility also failed to conduct a timely and thorough investigation of the alleged violation.
Deficiencies (4)
F602: The facility failed to protect all residents from misappropriation of property when Resident #1's laptop was missing and could not be located during the investigation. The resident required minimal to moderate assistance with activities of daily living and reported the laptop missing after switching rooms.
F609: The facility failed to report an allegation of possible misappropriation to the State Survey Agency within 24 hours and failed to notify local law enforcement as required. The facility's policy required immediate reporting of abuse, neglect, and misappropriation.
F610: The facility failed to conduct a timely and thorough investigation of the alleged misappropriation, including failure to begin an immediate investigation and to document interviews with staff and residents. The investigation did not include all required components.
A8023: The facility failed to develop and implement policies that prohibit mistreatment, neglect, abuse, and misappropriation of resident property and failed to require reports to the department for any resident or vulnerable person with reasonable cause to believe abuse or neglect occurred.
Report Facts
Resident census: 28
Plan of Correction completion date: POC completion date for deficiencies is 2025-01-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Named in relation to failure to report and investigation of misappropriation |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding missing laptop and investigation |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding missing laptop and investigation |
| MDS Coordinator | MDS Coordinator | Interviewed regarding missing laptop and investigation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding missing laptop and investigation |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Interviewed regarding allegations of misappropriation |
| Certified Medication Technician C | Certified Medication Technician (CMT) | Interviewed regarding allegations of misappropriation |
| Registered Nurse D | Registered Nurse (RN) | Interviewed regarding allegations of misappropriation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 21, 2024
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: May 21, 2024
Visit Reason
This document is a recertification survey and licensure inspection for Willard Care Center conducted to assess compliance with health and state licensure requirements.
Findings
The health portion of the recertification survey did not result in any deficiencies. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 21, 2024
Visit Reason
The inspection was conducted as a life safety code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association.
Findings
The Emergency Preparedness portion of the survey did not result in deficiencies. The facility met the applicable provisions of the 2012 Life Safety Code. No state licensure deficiencies were cited during this full inspection.
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 2
Date: Jun 24, 2021
Visit Reason
The inspection was conducted to assess compliance with quality of care regulations, specifically related to monitoring and physician notification for a resident with COVID-19 and a change of condition.
Findings
The facility failed to consistently contact the physician and document monitoring and full assessments for one resident with COVID-19 and a change of condition. The resident's vital signs, symptoms, and physician notifications were not properly documented as required by facility policy.
Deficiencies (2)
F684 Quality of Care: The facility failed to contact the physician and consistently document monitoring and full assessments of one resident with COVID-19 and a change of condition. The resident's vital signs and symptoms were not fully assessed or reported as required.
A4074 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with the resident's condition and current nursing practice. This deficiency references F684.
Report Facts
Facility census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Runnell | Administrator | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited on this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 8
Date: Mar 10, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for nursing care, restorative nursing, medication administration, infection control, and other resident care requirements.
Findings
The facility was found deficient in multiple areas including reasonable accommodations for resident needs, encoding and transmitting resident assessments, restorative nursing care, respiratory care, behavioral health services, medication administration, dental services, and infection prevention and control. Deficiencies were documented with specific resident cases and policy reviews.
Deficiencies (8)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure one resident had an appropriate wheelchair for safety and comfort, resulting in foot pedals being removed without proper evaluation or alternative provided.
F640 Encoding/Transmitting Resident Assessments: The facility failed to electronically transmit encoded Minimum Data Set assessments within 14 days for three residents, and lacked a policy regarding transmitting MDS data.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for one resident with limited mobility.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to develop and implement interventions for use of a BiLevel Positive Airway Pressure machine and obtain a physician order for oxygen for one resident.
F740 Behavioral Health Services: The facility failed to meet the psychosocial needs of one resident with depression, including lack of follow-up on mood assessments and inadequate communication with the physician.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure medication error rates were below 5 percent, with two errors out of 34 opportunities affecting two residents.
F790 Routine/Emergency Dental Services in SNFs: The facility failed to assist residents in obtaining routine and emergency dental care and did not document or follow up on dental concerns for several residents.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper use of gloves, cleaning protocols, and staff training.
Report Facts
Facility census: 52
Sample size: 17
Medication error rate: 5.88
Medication opportunities: 34
Medication errors: 2
Inspection Report
Routine
Census: 52
Deficiencies: 8
Date: Mar 10, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, assessment data transmission, range of motion care, respiratory care, behavioral health services, medication administration, dental care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide an appropriate wheelchair for one resident, failure to electronically transmit MDS assessments timely for three residents, inadequate range of motion care for one resident, improper respiratory care and lack of physician order for oxygen for one resident, failure to meet psychosocial needs of one resident with depression, medication administration errors affecting two residents, failure to address dental needs of one resident, and lapses in infection prevention practices by housekeeping staff.
Deficiencies (8)
Failure to ensure one resident had an appropriate wheelchair for safety and comfort, including removal of foot pedals without proper evaluation or documentation.
Failure to electronically transmit encoded Minimum Data Set (MDS) assessments within 14 days for three residents.
Failure to provide appropriate treatment and services to prevent further decrease in range of motion for one resident with contractures.
Failure to ensure proper cleaning and maintenance of a BiPAP machine and failure to obtain a physician order for oxygen for one resident.
Failure to meet psychosocial needs of one resident with depression, including lack of follow-up on depression scores and no offer of therapy or psychological services.
Medication administration errors resulting in an error rate of 5.88%, including administration of incorrect vitamin D dosage and crushing of Depakote tablets instead of using prescribed sprinkles capsules.
Failure to address dental needs of one resident, including lack of documentation and follow-up on dental pain and broken teeth.
Failure to follow infection prevention practices, including improper glove use and hand hygiene by housekeeping staff during cleaning tasks.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 5.88
Residents affected: 2
Residents affected: 1
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Administered medication with errors |
| LPN B | Licensed Practical Nurse | Interviewed regarding wheelchair, ROM, respiratory care, dental care |
| RN E | Registered Nurse | Interviewed regarding wheelchair, ROM, respiratory care, dental care |
| CNA F | Certified Nursing Assistant | Interviewed regarding wheelchair and ROM care |
| CNA G | Certified Nursing Assistant | Interviewed regarding wheelchair and ROM care |
| CNA H | Certified Nursing Assistant | Interviewed regarding ROM and dental care |
| Rehabilitation Director | Interviewed regarding therapy and restorative care | |
| Director of Nursing | Director of Nursing | Interviewed regarding wheelchair, ROM, respiratory care, dental care, infection control |
| Social Services Director | Social Services Director | Interviewed regarding behavioral health and dental care |
| Housekeeper C | Housekeeper | Observed and interviewed regarding infection control practices |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding infection control training and practices |
| Administrator | Administrator | Interviewed regarding medication administration and infection control |
Inspection Report
Life Safety
Census: 52
Capacity: 66
Deficiencies: 4
Date: Mar 10, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code provisions of the 2012 edition of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the smoke resistive properties of corridor doors and smoke barrier doors by allowing gaps and obstructions that could permit smoke passage. These deficiencies had the potential to affect all residents, staff, and visitors in the event of a fire.
Deficiencies (4)
K363 Corridor doors did not maintain smoke resistive properties due to gaps around closed doors and obstructions preventing full closing and latching. Gaps were observed in resident rooms 410, 205, and 204.
K374 Smoke barrier doors had gaps between doors and were insufficiently sealed when the fire alarm system was activated. Gaps were noted near room 405 and in the secured unit hall.
A2054 Smoke section walls and doors did not meet the requirement for one-hour fire-rated walls and doors that close automatically upon fire alarm activation. Refer to K374 for details.
A3001 The building was not substantially constructed and maintained in good repair as required by regulation. Higher classification was merited due to the extent of the violation. Refer to K363.
Report Facts
Facility capacity: 66
Census: 52
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 2
Date: Feb 1, 2019
Visit Reason
The inspection was conducted to assess infection prevention and control practices at Willard Care Center and to address deficiencies related to infection control and communicable disease regulations.
Findings
The facility failed to use appropriate infection control measures, including hand hygiene during incontinence care for two residents. The facility did not meet requirements for infection prevention and control programs and communicable disease reporting.
Deficiencies (2)
F880 Infection Control: The facility failed to use appropriate hand hygiene during incontinence care for two residents, increasing risk of spreading infections. The infection prevention and control program did not meet regulatory requirements.
A4085 Infection Control/Communicable Disease: The facility did not comply with regulations requiring reporting of communicable diseases to the state within seven days.
Report Facts
Facility census: 48
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Russell | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Director of Nursing | Provided statements regarding infection control training and expectations |
Inspection Report
Life Safety
Census: 48
Capacity: 66
Deficiencies: 2
Date: Feb 1, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations.
Findings
The facility failed to maintain the smoke resistive properties of the smoke barrier walls, allowing openings into the attic that could permit smoke spread. Additionally, several fire sprinkler escutcheons were loose or missing, exposing holes around sprinkler heads.
Deficiencies (2)
K372: The facility failed to maintain the smoke resistive properties of the smoke barrier walls by allowing openings into the attic. Loose or missing fire sprinkler escutcheons were observed in multiple locations, exposing holes around sprinkler heads.
A2054: Each smoke section shall be separated by one-hour fire-rated walls and doors. This regulation was not met as evidenced by the deficiencies noted in K372.
Report Facts
Facility capacity: 66
Resident census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Una Rummel | Administrator | Signed the statement of deficiencies and plan of correction |
| Maintenance Director | Interviewed regarding sprinkler escutcheons and responsible for corrective actions |
Inspection Report
Routine
Census: 48
Deficiencies: 1
Date: Jan 29, 2019
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on hand hygiene practices during incontinence care for two residents.
Findings
The facility failed to use appropriate infection control measures, as staff did not consistently perform hand hygiene before and after glove use during peri-care and incontinence care for residents. Observations and interviews confirmed multiple instances of staff not washing or sanitizing hands as required.
Deficiencies (1)
Failure to use appropriate hand hygiene during incontinence care for two residents.
Report Facts
Residents affected: 2
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) A | Observed failing to perform hand hygiene during peri-care. | |
| Certified Nurse Assistant (CNA) D | Observed failing to sanitize hands during catheter care. | |
| Registered Nurse (RN) B | Interviewed regarding hand hygiene expectations. | |
| Nurse Assistant (NA) C | Interviewed regarding hand hygiene practices during peri-care. | |
| Director of Nursing (DON) | Interviewed regarding training and expectations for hand hygiene. |
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 3
Date: Jan 17, 2018
Visit Reason
The document is a Plan of Correction submitted by Willard Care Center following a survey conducted from 01/08/2018 to 01/17/2018. It addresses deficiencies cited during the inspection related to medication errors, medication storage, and infection control.
Findings
The facility was found deficient in ensuring residents were free from significant medication errors, proper labeling and storage of drugs and biologicals, and maintaining an effective infection prevention and control program. Specific issues included delayed food consumption after insulin administration, expired medications in storage, and inadequate infection control practices during nebulizer treatments.
Deficiencies (3)
F760 Residents are not free of significant medication errors as staff failed to ensure timely food consumption after insulin administration for residents #3 and #193. The facility census was 40.
F761 The facility failed to store all drugs and biologicals properly, with expired medications found in the medication storage room affecting residents #5, #18, and #22. The facility census was 40.
F880 The facility failed to establish and maintain an infection prevention and control program, including improper hand hygiene and nebulizer treatment procedures, potentially exposing residents to infection.
Report Facts
Facility census: 40
Units of Novolog insulin administered: 6
Blood sugar level: 303
Number of expired stock medications: 27
Number of expired prescription medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Observed administering insulin and involved in medication error finding |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and medication administration |
| Certified Medication Technician C | Certified Medication Technician | Observed during nebulizer treatment and infection control deficiencies |
| LPN F | Licensed Practical Nurse | Observed performing blood sugar checks and medication administration |
Inspection Report
Life Safety
Census: 40
Capacity: 66
Deficiencies: 7
Date: Jan 8, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and building construction regulations.
Findings
The facility failed to maintain fire safety standards including unsealed holes from resident rooms into the attic, obstructed and locked egress doors, and inadequate protection of cooking facilities. Additionally, the emergency generator was not properly inspected or documented.
Deficiencies (7)
K161: The facility failed to maintain the fire rating by leaving holes unsealed from resident rooms into the attic, risking smoke spread in a fire. Rooms 409, 202, 301, 304, and 308 had unsealed holes.
K222: The facility failed to maintain exits free and clear as two of six magnetically locked exits did not release upon fire alarm activation. The magnetic locks remained energized holding doors closed.
K324: The facility failed to protect residents from fire hazards in the kitchen by allowing doors between the kitchen and main hallway to remain open without closure devices. The dish room door was propped open.
K918: The facility failed to perform complete weekly inspections and document emergency generator maintenance, including checking belts, hoses, and transfer switch times. Records showed no documented checks.
A2008: Hazardous areas were not separated by at least one-hour fire-resistant construction as required, referencing deficiency K324.
A2037: Exit requirements for multi-story facilities were not met, referencing deficiency K222.
A3001: The building was not substantially constructed or maintained per regulations, referencing deficiency K161.
Report Facts
Facility capacity: 66
Resident census: 40
Observation dates: Jan 8, 2018
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