The Willows

What the state also noted

• — This facility carries serious findings. On 11/05/2025 the state declared an Immediate Jeopardy situation because the center failed to ensure Resident #2 received the correct medications from qualified staff; the resident became hypotensive and was treated in an intensive care unit. Families should read the full November 2025 survey.
• — Four deficiencies were cited on 11/07/2025: an out-of-date service plan, a medication aide working with an expired certification, the medication finding the state classified as Immediate Jeopardy — its most serious level — and staff not observing a resident swallow medications.
• — The administrator told surveyors there was no actual process in place for notifying a resident's physician after a medication error, the physician was not notified, and the resident's home health provider was never told of the error or the hospital visit — they found out incidentally on 11/04/25.
• — Both staff involved told surveyors they received no in-service or education after the 10/30/25 medication error. Mandatory medication-administration training did not occur until 11/07/2025, after the state declared Immediate Jeopardy and required a plan of removal.
• — OSDH rejected the facility's first plan of correction for the out-of-date service plan finding on 12/05/2025 as unacceptable and required an amended plan.
• — The June 2025 survey did cite a bed bug/pest control deficiency at the time — the state recorded it as a pattern, affecting several residents, covering 2 of 3 sampled residents; it was only removed on 08/08/2025 after the facility's informal dispute request and the state's administrative review.
• — The pest-control positives above are drawn from the body of that same June 2025 citation, which also documents: an Adult Protective Services referral dated 02/13/25 for Resident #3 having bed bug bites; the administrator confirming bed bugs had been seen on Resident #3's cushion; bed bugs found in Resident #7's room while changing linens; a nurse aide confirming bugs were identified in the lobby couch and chair ('Yes, that's why I don't sit over there'); and monthly pest control invoices that 'did not specify which areas or apartments were treated.' The administrator also reported skin assessments were not performed on a routine basis.
• — The count of substantiated complaints is our best mapping of cited deficiencies back to the ten complaint numbers listed; OSDH does not label each complaint substantiated or unsubstantiated in these documents.
• — Several positives above rest on allegations that were investigated without a citation resulting. That means the state did not find a violation on those points — it is not an affirmative finding that the area is strong.
• — The documents are scans run through text recognition, and some of the text came out garbled. Examples: the facility's informal dispute request form lists the disputed pest-control citation as 'C1570' where the State Form shows C1507, and the plan of removal dates the medication error '10/30/2026 [sic]' when the error occurred 10/30/2025.