MARION, AR - Federal health inspectors issued immediate jeopardy citations to Willowbend Health and Rehabilitation following a February 2025 inspection that documented hazardous materials left accessible to wandering residents, expired narcotic medications stored in treatment carts, and widespread food safety failures affecting meal preparation and sanitation.
Critical Safety Violations Put Residents at Risk
During the February 6, 2025 inspection, surveyors documented the facility's most serious violation when they observed a clear plastic bag containing medications, lighters, aerosol sprays, and other hazardous materials left unattended at wheelchair height on the 100 Hall nursing station counter. The bag remained accessible to residents with cognitive impairments who regularly wandered the hallway.
The contents of the unsecured bag included antibiotic ointment, ibuprofen, alcohol spray, perfume, two lighters, and aerosol deodorant spray. Certified Nursing Assistant (CNA) #12 acknowledged during the inspection that Resident #19, who was observed wandering the hallway, "could come up here, grab this bag and take off down the hall with it." The CNA then left the materials unattended while transporting trash and linen down the corridor.
When questioned about the placement of these items, CNA #12 stated the bag "should have been stored out of reach and behind a door to keep residents out of it." The staff member further acknowledged that the contents were "hazardous to the residents, and they could drink something, or injure themselves."
The facility's own policy on Accident Hazards Prevention requires that "the environment will be free from accident hazards as is possible" and mandates that staff at all levels engage in ongoing safety training. Licensed Practical Nurse (LPN) #14 confirmed during the inspection that hazardous materials should be kept out of residents' reach.
The placement of medications and flammable materials at accessible heights creates multiple safety risks. Residents with dementia or cognitive impairments may not recognize dangerous substances and could ingest medications not prescribed to them, potentially leading to overdose or adverse drug interactions. Aerosol sprays can cause respiratory distress if sprayed directly or ingested, while unsecured lighters present fire hazards in a residential healthcare setting. The presence of alcohol-based products compounds these risks, as ingestion can cause intoxication, metabolic acidosis, and central nervous system depression.
Expired Narcotic Medication Found in Treatment Cart
Inspectors discovered multiple expired medications during their examination of the facility's medication carts, including a narcotic pain reliever prescribed to a specific resident. The February 4, 2025 inspection of medication cart #2 revealed morphine 20 milligrams/milliliter solution that had passed its expiration date, along with six other expired over-the-counter medications including acetaminophen, aspirin, ibuprofen, and milk of magnesium.
A separate medication cart inspection documented six additional expired items, including regular strength antacid, nail repair solution, stool softener, nutritional supplements, and extended-release acetaminophen. In total, 13 expired medication products were found across the two carts examined.
Resident #71, to whom the expired morphine was prescribed, had been admitted to the facility in October 2020 with Parkinson's disease. The resident's care plan, initiated in April 2023, identified pain management as a concern and included instructions to "administer pain medications as ordered/needed" and to "notify MD/Practitioner if not effective."
The use of expired medications presents clinical concerns beyond simple ineffectiveness. Morphine and other opioid analgesics can degrade over time, potentially forming breakdown products that may be toxic or cause unexpected reactions. While the primary risk with most expired medications is reduced potency, the presence of degraded compounds in narcotic medications raises additional safety questions. For a resident with Parkinson's disease experiencing pain, receiving ineffective analgesia due to medication degradation could result in unnecessary discomfort and decreased quality of life.
According to facility policy titled "Medication Storage in the Facility," all expired medications should be removed from active supply and destroyed, with controlled substances retained in a securely locked area until proper destruction. Staff interviews revealed that nurses were expected to notify the Assistant Director of Nursing (ADON) when medications were discontinued or expired, and that narcotics should be double-signed in a narcotic book before removal from medication carts.
The ADON confirmed that expired or discontinued narcotics should be placed in a double-locked drawer in the Director of Nursing's office until the pharmacist arrives for destruction or until two staff members verify the information for return to the pharmacy. However, the presence of expired morphine in the active medication cart indicates this protocol was not followed consistently.
Widespread Food Service Failures Compromise Nutrition
The inspection documented systematic failures in meal preparation that resulted in residents receiving inadequate portions and missing menu items. On February 4, 2025, inspectors observed Dietary Cook (DC) #2 preparing mechanical soft turkey for the evening meal by placing only 23 ounces of ground turkey in the oven for 21 residents requiring mechanically altered diets. The facility menu specified that each resident should receive 4 ounces of turkey, requiring a total of 84 ounces for proper portions.
When an additional 5.1 ounces was prepared later, the total amount available was only 28 ounces—approximately one-third of what was needed. DC #2 served single portions using a #12 scoop containing 3 ounces instead of the required 4 ounces, further reducing the protein content of the meal.
The kitchen completely ran out of stuffing and broccoli during the dinner service. After depleting the supply, staff used a smaller scoop to serve stuffing, providing residents with 3 ounces instead of the planned 4 ounces. Four residents received cut green beans as a substitute when broccoli was unavailable. One resident specifically requested broccoli and was informed by the Dietary Manager that the kitchen had run out.
During breakfast service on February 5, 2025, residents requiring pureed diets received neither pureed hash browns nor pureed biscuits as specified on the facility menu. When questioned, DC #2 stated she "forgot" to prepare these items.
Proper nutrition is fundamental to resident health in long-term care settings, particularly for individuals requiring texture-modified diets. Residents prescribed mechanical soft or pureed diets typically have dysphagia or swallowing difficulties that place them at risk for aspiration pneumonia. These dietary modifications require careful preparation to ensure adequate caloric and protein intake while maintaining food safety.
The observed portion shortfalls have direct nutritional implications. Protein deficiency can lead to muscle wasting, delayed wound healing, weakened immune function, and increased susceptibility to pressure injuries—complications that are already common concerns in nursing home populations. Missing menu items mean residents did not receive the balanced nutrition planned by the dietary department and approved to meet their needs.
Food Safety Violations Create Infection Risk
Beyond inadequate portions, the inspection revealed extensive food safety violations that could expose residents to foodborne illness. Inspectors documented numerous undated food items in refrigerators, freezers, and dry storage areas, making it impossible to determine freshness or adherence to safe storage timeframes.
In the walk-in refrigerator, surveyors found a plastic bag of raw chicken drumsticks on the third shelf "dripping liquid out of the right bottom corner." The Dietary Manager acknowledged that raw chicken should be stored on the bottom shelf to prevent cross-contamination with other foods. Additional raw chicken wings were discovered on the third shelf next to other food boxes without any date marking.
Temperature monitoring revealed potentially dangerous conditions. Ground turkey on the steam table measured 125 degrees Fahrenheit—ten degrees below the 135-degree minimum required to prevent bacterial growth. Pureed bread registered at only 91 degrees Fahrenheit, placing it firmly in the temperature danger zone where pathogens multiply rapidly.
Food held between 41 and 135 degrees Fahrenheit enters what food safety experts identify as the temperature danger zone, where bacteria such as Salmonella, E. coli, and Listeria can double in number every 20 minutes. For elderly nursing home residents with compromised immune systems, chronic health conditions, and often poor nutritional status, foodborne illness can result in severe dehydration, hospitalization, and potentially life-threatening complications.
The inspection documented poor hand hygiene practices among dietary staff. DC #2 was observed cutting turkey meat without changing gloves or washing hands after handling packaging materials. DC #3 used a spoon from a dirty sink to scoop broccoli without washing or sanitizing it first. Dietary Aide #4 touched condiments and supplements with bare hands, then handled beverage glasses by their rims without washing hands between tasks.
Equipment cleanliness presented additional concerns. The ice machine in the kitchen had "wet black residue" on the panel where ice forms and black residue in the corners. When the Dietary Manager wiped the area with tissue paper, the black slime easily transferred, despite the facility's claim that maintenance cleaned the machine monthly. A second ice machine in the nourishment room on the 300 Hall showed similar contamination. Staff confirmed that ice from these machines was used in beverages served to residents and in water pitchers placed in resident rooms.
The areas behind and beneath cooking equipment were found heavily soiled. The grease drip pan was filled over halfway with grease and food drippings, with crumb coatings that fell onto the kitchen floor when the pan was pulled out. The drip pan below the stovetop was covered with lima beans, burnt food debris, and grease. The backsplash had accumulated a thick layer of yellow grease, despite facility protocols requiring daily cleaning.
Additional Issues Identified
The inspection documented multiple other violations affecting facility operations. Open food containers in the freezer, including burritos and cookie dough, were neither covered nor sealed, exposing them to freezer burn and potential contamination. A full pitcher of pink flavored drink in a cooler had no lid or date marking. One staff member's personal lunch was stored in the walk-in refrigerator alongside food prepared for residents.
Kitchen storage areas contained food debris and required cleaning. The edges of the steam table had food stains, while shelves below the steam table and food preparation counter contained loose food crumbs. Greasy food particles accumulated on top of the oven.
Throughout the dry storage area, freezer, and refrigerator, inspectors found numerous items without received dates or opened dates, including marshmallows, pasta, hash brown patties, beef franks, ice cream, tomatoes, scrambled eggs, buttermilk, bologna, cucumber and onion mix, shredded lettuce, and coleslaw. Without proper date marking, staff cannot implement first-in-first-out rotation or determine when items should be discarded.
The facility's policy on handwashing and glove usage in food service, initiated in 2016, clearly states that food handlers should wash hands before starting work, after touching dirty dishes or clothing, and after touching anything else such as dirty equipment. The observed practices demonstrated that staff were not consistently following these established protocols.
Federal regulations require nursing homes to procure food from approved sources and to store, prepare, distribute, and serve food in accordance with professional standards. Facilities must ensure menus meet residents' nutritional needs, are prepared in advance, followed as written, and regularly reviewed by a dietitian. The violations documented at Willowbend Health and Rehabilitation represent failures across multiple aspects of these requirements, from menu adherence to food safety practices to equipment maintenance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willowbend Health and Rehabilitation, LLC from 2025-02-06 including all violations, facility responses, and corrective action plans.
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