Embassy of Willard

In the surveyor’s words

From the most serious findings on record at Embassy of Willard, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 24, 2025

  Based on facility bus observation, staff interviews, medical record review, review of the incident log, review of the facility internal investigation, review of facility provided photographs, review of hospital records, review of facility bus safety manual, review of facility bus wheelchair restraint user manual, review of wheelchair manual, and review of facility policy, the facility failed to ensure Resident #11, who was identified to be dependent on staff for all aspects of care, was safely secured with a seat belt and positioned properly in a wheelchair during a transport on the facility bus. […]

• No harm, potential for more than minimal, widespreadF838Jul 16, 2026

  Based on review of the facility assessment, staff interview, and policy review, the facility failed to ensure the facility assessment evaluated residents to determine the number of staff needed in the facility. This had the potential to affect all residents. The facility census was 55. Findings include:Review of the Facility Assessment last dated 04/02/26 stated the facility determined the facility needed one full time Director of Nursing (DON), one full time Assistant Director of Nursing (ADON), nine full time licensed nurse supervisors, five as needed licensed nurse supervisors, 17 full time nursing assistants, two part time nursing assistants, and four as needed nursing assistants for nursing staff. […]

• No harm, potential for more than minimal, patternF803Apr 25, 2024

  Based on observation, record review, and staff interview, the facility failed to ensure the menu was followed for residents receiving pureed diets. This affected six residents (#3, #27, #30, #37, #45, and #50) who were prescribed a pureed diet. The facility census was 50. Findings include: Review of the lunch meal spreadsheet for 04/23/24 revealed residents on a pureed diet should include pureed dinner rolls using one #20 scoop (equivalent to 3.5 tablespoons). Observation of tray line on 04/23/24 from approximately 12:15 P.M. to 12:45 P.M. revealed the facility did not include the pureed dinner rolls and/or an appropriate substitution to residents receiving pureed food items. Interview on 04/23/24 at 12:45 P.M. […]

• No harm, potential for more than minimal, patternF677Mar 23, 2022

  Based on medical record review, review of the shower schedule, staff and resident interview and policy review the facility failed to ensure residents were provided showers. This affected five residents (#01, #07, #17, #18 and #35) of six residents reviewed for assistance with activities of daily living. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #07 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident required the extensive assistance of two staff for transfers and the physical assistance of two staff for bathing. Review of the shower schedule last revised on 03/13/22 revealed Resident #07 was scheduled for showers on Tuesdays and Saturdays on third shift. […]

• No harm, potential for more than minimal, patternF725Mar 23, 2022

  Based on medical record review, review of the shower schedule, staff and resident interview and policy review the facility failed provide sufficient staffing to ensure residents were received showers. This affected five (#01, #07, #17, #18 and #35) of six residents reviewed for staffing assistance for activities of daily living. The facility census was 39. Findings include 1. Review of the medical record revealed Resident #07 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]