Cycle 1
Health 2024-09-26 · Fire 2024-09-26
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Willow Springs, MO
Willow Care Nursing Home
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2646 State Route 76, Willow Springs, MO
(417) 469-3152
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-10-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,818
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.97% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.52
Baseline 6.84% · Performance 7.08% · Measure score 2.52 · Achievement 2.52 · Improvement 0
Total nurse turnover
6.14
Performance 38.57% · Measure score 6.14 · Achievement 6.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.81
Baseline 3.74 hours · Performance 3.88 hours · Measure score 2.81 · Achievement 2.81 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 9.26% · Lower 95% interval 6.83% |
| Discharge to community | 53.56% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 47.06% · Lower 95% interval 38.53% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 78.13% |
95.27%
17.1 pts worse
|
Numerator 25 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 10 · Denominator 26 |
| Discharge mobility score | 23.08% |
50.94%
27.9 pts worse
|
Numerator 6 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.88% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 2.44% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 82 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 42.31% |
56.45%
14.1 pts worse
|
Numerator 11 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
84.8%
9.4 pts better
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 96.9% · Q3 96.8% · Q4 90.9% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
90.9%
6.2 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.8% |
4.1%
6.7 pts worse
|
3.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 12.3% · Q3 11.3% · Q4 9.1% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
14.7%
12.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.5%
0.9 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.8% · Q3 1.7% · Q4 3.2% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.6% |
25.3%
8.3 pts worse
|
19.6%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 31.1% · Q3 37.3% · Q4 32.8% · 4Q avg 33.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.3% |
25.0%
16.3 pts worse
|
16.7%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 44.4% · Q3 42.3% · Q4 36.4% · 4Q avg 41.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
20.3%
2.7 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 19.5% · Q3 9.3% · Q4 10.3% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
19.8%
2.3 pts better
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 14.0% · Q3 10.9% · Q4 17.2% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
18.1%
9.8 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.6% · Q2 33.0% · Q3 18.2% · Q4 18.8% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.0%
2.7 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.1% · Q3 4.1% · Q4 5.9% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.4% |
66.4%
7 pts better
|
81.7%
8.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 65.9% · Q3 66.7% · Q4 73.2% · 4Q avg 73.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.5% |
13.4%
14.1 pts worse
|
12.0%
15.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 31.0% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.2% |
2.2%
5 pts worse
|
1.6%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 15.0% · Q4 12.5% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.9% |
63.5%
2.6 pts worse
|
79.7%
18.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
25.3%
5 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 31.0% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-10 · Fire 2023-02-10
4 health deficiencies
Top issue: Environmental (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-01-10 · Fire 2020-01-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-02-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-02-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-22
E · Potential for more than minimal harm
2020-01-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-26
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-22
E · Potential for more than minimal harm
2020-01-10
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2020-02-09
D · Potential for more than minimal harm
2020-01-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-02-09
D · Potential for more than minimal harm
2020-01-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-02-09
D · Potential for more than minimal harm
2020-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-09
D · Potential for more than minimal harm
2020-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-09
Penalties and ownership
What sits behind the stars
Ownership
Willow Health Care Inc
5% Or Greater Direct Ownership Interest · Organization
Alter, Shirley
W-2 Managing Employee · Individual
Clark, Sheila
W-2 Managing Employee · Individual
Head, Barbara
W-2 Managing Employee · Individual
Miller, Sherry
Corporate Director · Individual
Miller, Sherry
W-2 Managing Employee · Individual
Ogden, James
Corporate Director · Individual
Williamson, Jackie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Kabul Nursing Homes Inc
Cabool, MO
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Mountain View Healthcare
Mountain View, MO
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Brooke Haven Healthcare
West Plains, MO
3-star overall rating with 3-star inspections with $10,033 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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