Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Park Rehabilitation Health Care Center during CMS and state inspections, most recent first.
Multiple residents with cognitive impairment were subjected to repeated physical aggression by another resident with severe behavioral disturbances, despite being on 1:1 supervision. The aggressor, who had a history of dementia and psychiatric diagnoses, continued to assault peers, resulting in injuries and hospital evaluation. Staff and leadership reported unsuccessful attempts to secure psychiatric placement or legal intervention, and staff expressed concerns about their ability to ensure safety due to the resident's unpredictable and escalating aggression.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, as observed by surveyors.
A resident with multiple comorbidities and a mechanically soft diet experienced a fatal choking episode during a meal. Staff attempted to clear the airway and confirmed the resident's DNR status, but did not call 911. The incident was not reported to the State Survey Agency, as facility leadership did not consider it suspicious or neglectful, despite policy requirements for reporting such events.
A resident with dementia was subjected to abuse by a CNA who placed her hand over the resident's mouth to prevent her from talking during care. The incident was reported by another resident, who was cognitively intact, to a CNA and an LVN. The facility's incident reports and progress notes lacked documentation of the abuse, and no harm was found upon assessment. The facility's abuse prohibition policy was not followed, violating the resident's right to be free from abuse.
A facility failed to document an incident involving a resident with dementia and Alzheimer's, lacking incident reports and progress notes for two days. Despite the LVN's claim of entering the information, the DON confirmed the absence of documentation, which is crucial for team communication.
A resident in full code status, admitted to hospice care, was found unresponsive and not breathing, but staff failed to initiate CPR, assuming the resident was DNR. This resulted in the resident's death, revealing a critical deficiency in the facility's emergency response procedures.
The facility failed to store and handle food according to professional standards, with observations of moldy produce, open and exposed food items, and improper thawing of meat in the kitchen. The Dietary Supervisor acknowledged conducting walkthroughs and checking temperature logs but did not prevent these storage issues, potentially risking food-borne illness for residents.
A resident with chronic pain related to arthritis was discharged without a documented discharge summary in their medical record. Interviews with facility staff revealed that discharge summaries are usually completed in the electronic medical records, but none was found for this resident. This failure to document the discharge summary is against the facility's policy, which requires detailed documentation and communication of discharge information.
A facility failed to develop a comprehensive care plan for a resident with diabetes, omitting measurable objectives and timeframes for diabetes management. Despite being prescribed and administered insulin, the resident's care plan did not address her diabetic condition. The MDS Coordinator was unaware of this omission, leaving staff without essential information for proper care.
A facility failed to ensure that a physician reviewed and documented the rationale for not following a pharmacist's recommendations for medication dose reductions for a resident with cognitive impairment. The resident was on multiple psychoactive medications, and the facility did not follow up on the pharmacist's suggestions. The DON acknowledged the oversight, and a policy on pharmacy recommendations was not provided when requested.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect multiple residents from abuse, specifically physical aggression perpetrated by another resident with a history of severe cognitive impairment and behavioral disturbances. Several incidents occurred in which this resident physically assaulted peers, resulting in injuries and hospital evaluation for at least one victim. The aggressive resident had a documented history of Alzheimer's disease, depression, bipolar disorder, anxiety, and mood disorder, with a severely impaired cognition score. Despite being placed on 1:1 supervision due to repeated aggressive episodes, the resident continued to initiate unprovoked physical aggression toward others, including hitting, pushing, and punching fellow residents. The affected residents, all with varying degrees of cognitive impairment and complex medical histories, were subjected to physical aggression on multiple occasions. One resident was hit in the chest and fell, requiring hospital evaluation; another was punched in the face; a third was pushed to the ground; and a fourth was struck on the arm. Care plans for these residents documented the incidents and included interventions such as removal from the aggressor and monitoring for injuries. However, these measures did not prevent further occurrences of abuse, and staff interviews revealed ongoing concerns about the safety of both residents and staff due to the aggressor's unpredictable and escalating behavior. Staff and leadership interviews indicated that attempts to secure psychiatric intervention or alternative placement for the aggressive resident were unsuccessful, as hospitals and other facilities declined admission, and legal barriers prevented emergency detention. Staff reported feeling unsafe and unable to manage the resident's physical aggression, citing the resident's size and strength. The facility's abuse prevention policy emphasized the importance of resident safety, but the repeated incidents and lack of effective intervention resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Ensure Resident #11 is placed on continuous 2:1 supervision at arm's length.
- Implement physical separation at arm's length between Resident #11 and all other residents at all times, accomplished by in-services to all staff.
- Place Resident #11 in a controlled, low-stimulation environment.
- Search the memory care common area and Resident #11's room to ensure objects that could be used to cause harm are removed from the resident's environment.
- Implement a two-staff approach for all care interactions involving Resident #11.
- Request and complete a psychiatric evaluation for Resident #11, with medication changes and additional diagnosis as a result.
- Review and adjust Resident #11's medication regimen and PRN parameters as clinically indicated.
- Review Resident #11's clinical status to assess for potential medical contributors to aggressive behavior, including pain assessment, vital signs, infection screening, bowel and bladder status, and medication profile.
- Revise the process for managing residents with aggressive behaviors, including early identification of triggers, defined escalation thresholds, and clear staff response expectations.
- Revise Resident #11's behavioral care plan by the interdisciplinary team to include identified triggers, early warning signs, de-escalation techniques, and clear direction for escalation.
- Educate DON and ADON regarding dementia-related aggressive behaviors, resident to resident abuse prevention, and de-escalation strategies, validated by quiz.
- Conduct education for staff on all shifts regarding dementia-related aggressive behaviors, resident-to-resident abuse prevention, and de-escalation strategies; staff, including PRN and Agency, will be unable to work until education is completed and validated by quizzes with a minimum score of 100%.
- Reinforce the Abuse Prevention Policy with specific focus on resident-to-resident aggression.
- Reinforce pathways of resources for staff for psychiatric consultation and alternative placement consideration and place in a binder at the nurses' station for staff accessibility.
- Conduct a house-wide assessment to identify residents at risk for harm, and implement protective interventions for all residents in the memory care unit.
- Provide immediate oversight of supervision levels and resident safety related to aggressive behaviors.
- Provide real time supervision during each shift to ensure protective interventions and separation measures remain in place; any escalation in aggressive behaviors results in immediate re-assessment and modification of interventions.
- Maintain active presence in oversight to ensure continued resident safety and adherence to interventions implemented to remove the jeopardy.
- Monitor resident-to-resident aggression through the QAPI program with trend analysis; review findings by the QAPI Committee and implement corrective actions as needed.
- Conduct ongoing audits to ensure compliance with supervision, care planning, and staff response protocols.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency are not provided in the report.
Failure to Timely Report Suspected Neglect Following Resident Choking Death
Penalty
Summary
The facility failed to report an incident of possible neglect to the State Survey Agency in a timely manner after a resident experienced a fatal choking episode during a meal. The resident, an elderly male with diagnoses including diabetes, vascular dementia, major depressive disorder, and anxiety, was on a mechanically soft diet and required meal assistance as needed. During dinner, the resident began choking, and staff attempted to clear the airway with a finger sweep and abdominal thrusts, but were unsuccessful. The resident's code status was confirmed as Do Not Resuscitate (DNR), and no signs of life were noted after the incident. Despite the severity of the event, the facility did not activate 911 emergency services during the episode. Interviews with facility staff revealed that the incident was not reported to the State Survey Agency because the Director of Nursing (DON) and Administrator believed it was not suspicious and did not constitute neglect, as they were aware of the circumstances and followed internal policy. The DON stated that not calling 911 was not considered neglectful, as it would not have changed the outcome. However, the facility's own policies required reporting all allegations and substantiated occurrences of abuse or neglect, including those resulting in serious bodily injury, to the state agency within specified timeframes. The failure to report the incident as required constituted a deficiency in the facility's abuse and neglect reporting procedures.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nursing Assistant (CNA) placed her hand over the resident's mouth to prevent her from talking while providing care. The resident, who had a history of dementia, Alzheimer's, cognitive communication deficit, and major depressive disorder, was unable to recall the incident due to her cognitive impairment. The incident was reported by another resident, who was cognitively intact, to a CNA and subsequently to a Licensed Vocational Nurse (LVN). The report was made after the incident occurred during the 2:00 PM to 10:00 PM shift. The facility's incident reports and progress notes did not document the abuse, and there was no head-to-toe assessment of the resident following the incident. Interviews with the Director of Nursing (DON) and LVN confirmed that the incident was reported and that the resident was assessed with no harm found. The facility's policy on abuse prohibition, which was intended to prevent abuse, neglect, and misappropriation of property, was not adhered to in this case, as the resident's right to be free from abuse was violated.
Incomplete Medical Records for Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding an incident that occurred on two consecutive days. The resident, a female with a history of dementia, Alzheimer's, cognitive communication deficit, and major depressive disorder, did not have incident reports, assessments, or nursing progress notes documented in her medical chart for the specified dates. This lack of documentation was identified during a review of the resident's face sheet, admission care plan, and MDS, which highlighted her cognitive impairment. Interviews with facility staff, including an LVN and the DON, revealed that the expected documentation was not present in the system despite the LVN's assertion that she had entered the necessary information immediately after assessing the resident. The DON confirmed the absence of documentation and emphasized the importance of timely record-keeping to ensure proper communication among the care team. The facility's policy on charting and documentation, revised in 2017, mandates that all services and changes in a resident's condition be recorded in their medical record to facilitate communication within the interdisciplinary team.
Failure to Initiate CPR for Full Code Resident on Hospice
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who was in full code status and required emergency care before the arrival of emergency medical personnel. The incident involved a resident who was unresponsive and not breathing, and the staff did not initiate CPR as required. The resident was declared deceased, and this failure was identified as an Immediate Jeopardy situation. The resident in question was an elderly female with a history of dementia, cognitive communication deficit, anemia, hypertension, anxiety disorder, and depression. She was admitted to hospice care but remained in full code status, meaning that life-saving measures like CPR should have been initiated in the event of an emergency. Despite this, the staff, including LVN B, did not perform CPR when the resident was found unresponsive, assuming incorrectly that the resident was DNR due to her hospice status. Interviews with facility staff revealed a lack of awareness and understanding of the resident's code status, leading to the failure to initiate CPR. Staff members, including LVN A and LVN B, admitted to assuming the resident was DNR because she was on hospice, without verifying her actual code status. This assumption led to the inaction that resulted in the resident's death, highlighting a critical deficiency in the facility's emergency response procedures.
Improper Food Storage and Handling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and handling of food items in the kitchen. Observations revealed multiple instances of food being improperly stored, including cantaloupes and onions with visible mold, open bags of shredded carrots and cheese exposed to air, and meat thawing in a container with blood dripping onto the floor. Additionally, the freezer contained open bags of tortilla chips and boxes of pork steak and beef patty fritters exposed to air. The dry storage area and seasoning shelf also had open containers of food items exposed to air, such as country style gravy mix, instant puree rice, instant food thickener, and ground nutmeg. The Dietary Supervisor, during an interview, stated that she conducted morning walkthroughs of the kitchen and checked temperature logs, ensuring that dietary staff stored food properly by addressing any issues. However, the observations indicated a failure to maintain proper food storage, which could place residents at risk for food-borne illness. The facility's policy on food receiving and storage, dated October 2022, and the FDA Food Code of 2017, both emphasize the importance of storing food in a manner that prevents contamination, which was not adhered to in this instance.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to ensure that a discharge summary was documented in the medical record of a resident who was discharged. The resident, who had chronic pain related to arthritis, was admitted to the facility and had a care plan that included interventions for pain management. However, upon discharge, there was no discharge summary or documentation of the discharge in the resident's medical records. This lack of documentation was confirmed through interviews with various staff members, including an LVN, the ADON, and the DON, who all indicated that discharge summaries are typically completed in the electronic medical records but were not found in this case. The facility's policy on transfer or discharge documentation requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving healthcare facility or provider. This includes information such as the basis for the transfer or discharge, the resident's condition, and the disposition of personal effects and medications. The absence of a discharge summary for the resident indicates a failure to adhere to this policy, potentially putting residents at risk of not receiving necessary care and services upon discharge.
Failure to Develop Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with diabetes. The care plan did not include measurable objectives and timeframes to address the resident's medical needs related to diabetes management. This oversight was identified during a review of the resident's quarterly MDS assessment and comprehensive care plan, which lacked any mention of the resident's diabetes diagnosis despite the resident being prescribed and administered insulin as per physician orders. Interviews with the resident and the MDS Coordinator revealed that the resident was aware of her diabetic condition and insulin treatment. However, the MDS Coordinator, who was responsible for updating the care plan, was unaware that the resident's care plan did not include diabetes management. The absence of an updated care plan meant that staff lacked the necessary information to provide adequate care for the resident's diabetes. Additionally, a policy regarding care plans was requested from the Administrator but was not provided.
Failure to Review and Document Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen irregularities identified by the pharmacist were reviewed by the attending physician, and that the physician documented their rationale for making no changes to the medications of a resident. Specifically, the pharmacist recommended gradual dose reductions for psychoactive medications prescribed to a resident, but these recommendations were not followed. The resident, who was cognitively impaired with a BIMS score of 3 out of 15, was taking multiple medications for conditions including anxiety, depression, and schizophrenia. The Director of Nursing (DON) admitted that the facility did not follow up with the pharmacist's recommendations for the month of August. The DON was informed by the Corporate Clinical Specialist that she was responsible for ensuring the physician was informed of pharmacy recommendations, but this was not done. Additionally, a policy regarding pharmacy recommendations was requested from the Administrator but was not provided. This oversight could potentially place residents at risk for prolonged use of unnecessary medications.
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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.
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Nursing homes near Clifton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Home | 1.1 mi | — | 0 | 0 |
| Goodall Witcher Nursing Facility | 5.9 mi | — | 0 | 0 |
| The Hilltop On Main | 10.8 mi | — | 7 | 0 |
| Whitney Nursing And Rehabilitation Center | 19 mi | — | 1 | 0 |
| Hillside Medical Lodge | 26.6 mi | — | 8 | 0 |
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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 August 2026) and official state health department websites.