Willard Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times when fans and vents were free of dirt and dust, when staff failed to discard a box of baking soda in the walk-in cooler with black substance on the container, when staff failed to air dry dishes before stacking, and when staff failed to ensure dishes were clean before stacking. The deficient practice had the potential to harm all residents. The facility census was 57.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for three residents (Resident #5, Resident #15, and Resident #31) after each resident sustained a fall with potential for head injury. The facility census was 57. Review of the facility policy titled, Condition Change, Resident (Observing, Recording, and Reporting) (Includes Fall or Injury)), undated, showed the following: -Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; -Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food was served at a safe and appetizing temperature when staff failed to hold four pureed meals at an appropriate temperatures prior to serve out. The facility census was 57. Review of the facility policy titled, Food Temperatures, dated May 2015, showed the following:-The Dietary Manager (DM) or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled;-Keep the temperature of hot foods no less than 140degrees Fahrenheit (F) during meal service;-Hot food should be at least 120 degrees F when served to the resident. Review of the facility policy titled, Food Preparation and Distribution, dated May 2015, showed the following:-Food is not placed in the steam table more than 30 minutes before meal service. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective infection prevention and control program when the facility failed to have processes in place to ensure all new staff were screened prior to employment for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when the facility failed to fully complete TB testing for five staff (Maintenance Director (MD), Medical Records (MR), Housekeeper (HK) C, Certified Nursing Assistant (CNA) A, and Registered Nurse (RN) B). The facility census was 57. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the initiation, reduction, or termination of Medicare Part A benefits for one of three sampled residents (Resident #1) who remained in the facility upon discharge from Medicare Part A services. The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment when staff failed to ensure one resident's (Resident #19) room was free of odors. The facility census was 57.1. Review of Resident #19's face sheet (brief resident profile) showed the following:-admission date of 03/20/26;-Diagnoses included fracture of unspecified part of neck of left femur (broken hip), vascular dementia (progressive decline in thinking, memory and behavior caused by impaired blood flow to the brain), heart disease, stroke, and obsessive compulsive disorder (chronic mental health condition characterized by uncontrollable recurring thoughts and repetitive behaviors). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a system in place that clearly and consistently represented each resident's choice of code status (whether or not the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency procedure used during cardiac or respiratory arrest)) when staff failed to ensure two residents' (Resident #1 and Resident #26) code status was consistent throughout the medical record. The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all resident with pressure ulcers received care per standards of practice when staff failed to properly identify, adequately assess, and monitor the skin condition for one resident (Resident #2) with two pressure ulcers, one stage 3 (a full thickness skin loss injury, appearing as a deep crater extending through the dermis into subcutaneous fat), and one unstageable (a full thickness tissue loss where the actual depth is hidden below eschar (tan, brown, or black hardened tissue). The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent possible urinary tract infections (UTIs) when staff allowed the resident's urinary catheter (a thin, flexible tube inserted into the body to drain urine) tubing to touch the floor, increasing the risk of infection for one resident (Resident #2). The facility census was 57. Review of the facility policy titled, Catheter, Emptying a Urinary Drainage Bag, undated, showed staff to keep the drainage bag and tubing off the floor, at all times, to prevent contamination and damage. 1. Review of Resident #2's face sheet showed:-admission date of 08/20/25;-Diagnoses included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) had physician orders for the care of his/her colostomy (a surgical procedure that creates an opening, called a stoma, in the abdominal wall) . The facility census was 57. Review of the facility policy titled, Colostomy and Ileostomy (a surgical procedure where the end of the small intestine (the ileum) is redirected through a new opening in the abdominal wall, called a stoma) Care, undated, purpose to prevent infection, skin irritation, alleviate unpleasant odors, and to obtain accurate bowel measurement output.1. Review of Resident #6's face sheet showed:-admission date of 02/04/25;-Diagnoses included paraplegia (paralysis of the lower half of the body), anxiety and depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents with mental health services as needed when staff failed to consistently notify the physician and failed to develop a care plan regarding statement regarding death made by one resident (Resident #7) that made suicidal comments. The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician ordered medication was available for resident use for one resident (Resident #6) when staff did not obtain and did not administer his/her ordered bladder spasm medication for approximately four weeks. The facility census was 57. Review of the facility policy titled, Medications, Errors and Drug Reactions, undated, showed, in part, the following:-Purpose to safeguard the resident and provide emergency care as necessary;-Report all medication errors immediately to the resident's physician, Director of Nursing (DON), and Administrator;-Document and follow the physician orders. 1. Review of Resident #6's face sheet showed:-admission date of 02/04/25;-Diagnoses included overactive bladder, neuromuscular dysfunction of the bladder, anxiety and depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete regular inspections of the bed frame and side rails for risk of entrapment for one resident (Resident #51) whose side rails were loose. The facility census was 57. Review of the facility policy, titled Bed Rails, undated, showed the following:-Bed rails are constructed of metal or plastic, and are available in various sizes (full length, half, or quarter rails). Bed rails may be positioned in various locations on the bed: upper or lower, one or both sides;-When installing or maintaining bed rails, staff should follow manufacturer's recommendations and specifications for applicable bed rails, mattresses and bed frames;-Staff will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure notification to the resident's family/responsible party of changes of condition for all when residents when staff failed to document family/responsible party notification of four residents (Resident #1, #2, #3, and #4) for resident change in health condition, resident falls, and/or new physician orders. The facility had a census of 58. Review of the facility provided Patient [NAME] of Rights as provided by the Long-Term Care Ombudsman (advocate for residents in nursing homes and assisted living facilities who helps protect their rights, health, and quality of life) Program, showed the resident had the right to:-Be fully informed of services available to you;-Participate in planning your care and being informed of all aspects of your care. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep all residents free from significant medication errors when staff administered one resident's (Resident #1) medication (ferrous sulfate - iron supplement) at the incorrect frequency for 82 days. A sample of four residents was reviewed for medication administration in a facility with a census of 56. Review of the facility policy entitled, Physician Orders, undated, showed medication orders should include type, route, dosage, frequency, and strength of the medication ordered. Review of the facility policy entitled, Medication Administration, revised 02/07/13, showed the following information:-Medications are given to benefit a resident's health as ordered by the physician;-Read the label three times before administering the medication. First when comparing the label with the medication sheet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure all residents maintained acceptable parameters of nutritional status with the facility failed to follow-up and implement Registered Dietitian (RD) recommendations for two residents (Resident #1 and #4) with wounds and for three residents (Resident #2, #3, and #4) who were identified as under body weight. The facility census was 37. Review of the facility's House Supplement Guidelines, dated May 2015, showed supplements are indicated when resident's intake at meals is not adequate to maintain weight, weight gain is needed, or weight loss is too rapid. Review of the facility's Supplement Guidelines, dated May 2015, showed the following: -Physician ordered supplements should be prepared and delivered by the dietary department; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and physical, mental, and psychosocial well-being for residents when the facility to provide meaningful activities for all residents, including two residents (Resident #1 and #2), and failed to care plan one resident's (Resident #2) specific activity interest. A sample of 8 residents was selected for review. The facility census was 31. Review of the facility's policy titled Role of the Activity Director, dated 03/2012, showed the following: -The activity director provides a key role in enhancing the quality of a resident's daily life. The activity director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegation of possible abuse were were reported to the state survey agency (Department of Health and Senior Services-DHSS) within the required time frame when staff did not report an allegations of possible abuse involving two residents (Resident #1 and Resident #2). The facility had a census of 39. Review of the facility's Abuse and Neglect policy titled, Reporting, undated, showed the following: -It is the policy of the facility that each resident will be free from abuse: -Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, exploitation, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were fully and timely investigated when staff did not complete investigations of allegations of possible resident to resident abuse involving two residents (Resident #1 and Resident #2). The facility census was 39. Review of the facility abuse policy titled, Investigation, undated, showed the following: -It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated; -The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care to all pressure ulcers per standards of practice when the facility failed to have a system in place to obtain wound care orders, ensure timely implementation of new wound care orders, to ensure timely physician notification of wounds, and to document and track wounds timely and completely for one resident (Resident #3) who admitted with stage 2 pressure ulcers (a partial thickness skin loss, appearing as a shallow open sore or a blister, where the top layer of skin (epidermis) and potentially the deeper layer (dermis) are damaged, resulting in a red or pink wound bed without exposed muscle or bone; it can also present as an intact or ruptured blister) on his/her buttocks. A sample of 8 residents was reviewed in the facility with a census of 31. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect all residents from misappropriation of property when one resident's (Resident #1) laptop, that was listed on the resident's inventory of personal effects, could not be located. A sample of four residents was reviewed in the facility with a census of 28. Review of the facility's policy titled Abuse Prohibition Protocol Manual, undated, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat-the-resident's-medical-symptoms; -Each resident has the right to be free from misappropriation of property and exploitation; [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of possible misappropriation to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required twenty-four hour timeframe after facility staff became aware of the allegation of misappropriation of property for one resident (Resident #1). The facility failed to notify local law enforcement of the allegation of misappropriation. A sample of four residents was reviewed in the facility with a census of 28. Review of the facility's undated policy titled Abuse Prohibition Protocol Manual showed the following: -Each resident has the right to be free from misappropriation of property and exploitation; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely and thorough investigation of all allegations of misappropriation when staff failed begin an immediate investigation into one resident's (Resident #1) allegation of misappropriation and failed to document interviews with multiple staff and residents as part of the investigation. A sample of four residents was reviewed in the facility with a census of 28. Review of the facility's policy titled Abuse Prohibition Protocol Manual, undated, showed the following: -It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated; -The investigation is the process used to try to determine what happened. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff) assessments from the facility to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days after completion for three residents (Resident #1, Resident #2, and Resident #18) out of a sample of 17 residents selected for review. The facility had a census of 52 residents. The facility did not have a policy regarding transmitting MDS data. 1. Record review of Resident #'1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not change his/her gloves and wash his/her hands between dirty and clean tasks. The facility had a census of 52 residents. Record review of the facility's infection control policy, titled Cleaning and disinfecting resident rooms, dated November 2008, showed the following information: -Housekeeping services (example, floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; -Use heavy-duty gloves and other personal protective equipment) for housekeeping tasks; -Heavy-duty gloves may be reused as long as the integrity of the gloves is intact and they are disinfected regularly; -Perform hand hygiene after removing gloves. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident #31) had an appropriate wheelchair for safety and comfort out of a selected sample of 17 residents. The facility's census was 52. 1. Record review of Resident #31's face sheet (a document that gives a resident's information at a quick glance) showed the resident admitted to the facility on [DATE]. His/her diagnoses included pressure ulcer of his/her right buttock, dementia, post-polio syndrome (gradual new weakening in muscles that were previously affected by the polio infection), joint disorder and weakness. Record review of the resident admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 12/10/19, showed the following information: -Severe Cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #31), with limited range of motion, received appropriate treatment and services to prevent a further decrease in range of motion in a selected sample of 17 residents. The facility's census was 52. 1. Record review of Resident #31's face sheet (a document that gives a resident's information at a quick glance) showed staff admitted the resident to the facility on [DATE]. The resident's diagnoses included pressure ulcer of the right buttock, dementia, anxiety, joint disorder and weakness. Record review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/19, showed the following information: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure proper cleaning and maintenance of a BiLevel Positive Airway Pressure (BiPAP) (a non-invasive form of therapy for people suffering from sleep apnea (temporary cessation of breathing, especially during sleep)), failed to develop and implement interventions for use of a BiPAP and failed to obtain a physician order for oxygen for one resident (Resident #18) in a selected sample of 17 residents. The facility's census was 52. Record review of the facility's Bilevel Positive Airway Pressure (BiPAP) Administration policy, dated March 2015, showed the following information: -Purpose: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the psychosocial needs of one resident (Resident #27) who had a diagnosis of depression in a selected sample of 17 residents. The facility's census was 52. Record review of Resident #27's face sheet showed the resident originally admitted on [DATE]. Record review of the resident's current physician orders showed, in part, the following orders: -An order dated 9/17/19, for Duloxetine, 60 milligrams (mg), daily for major depressive disorder; -An order dated 9/17/19, for Trazodone, 50 mg, at bedtime for major depressive disorder. Record review of the resident's Social Services New admission Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool completed by facility staff) assessment note dated 9/23/19, at 1:28 P.M., showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 34 opportunities, resulting in an error rate of 5.88 percent affecting two residents (Resident #26 and #38). The facility's census was 52. 1. Record review of Resident #26's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, persistent mood disorder, anxiety disorder, and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address one resident's (Resident #21) dental needs failed to document regarding dental pain, broken teeth, or other dental needs for the resident in a selected sample of 17 residents. The facility's census was 52. Record review of the facility's policy, dated March 2015, titled Oral Hygiene, showed the following information: -Offer oral hygiene before breakfast, after each meal and at bedtime. -Inspect mouth and gums for irritation or open areas. 1. Record review of Resident #21's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -readmitted to the facility on [DATE]; -Diagnoses included stroke, heart failure, diabetes and dementia. Record review of the resident's Physician Order Sheet (POS) showed an order, dated 6/5/19, for a dental consult as needed. [...]