The medical power of attorney for the resident discovered the pattern only when doctors' offices called wondering where she was. "The first time the van driver took him to a Dr. appointment, wearing a wander guard bracelet and left him without checking to see if I was there was in October of 2024," she told federal inspectors during a phone interview. "I found out he had an appointment when I received a phone call from the Dr's office letting me know he was there and stated they were surprised I wasn't with him."
The doctor's office knew to expect her. "They know me there and know that I am always with him," she said.
It happened again on January 9, 2025. Then January 28, 2025.
After the third incident, she complained to the Director of Nursing on January 29. The nursing director didn't respond for four days. When she finally called back on February 2, she said the van driver had been transferred and would no longer drive for the facility.
Federal inspectors who visited Willows Center in late October found the facility had violated requirements to immediately notify residents' families of situations affecting their care. The 91-bed facility on Summers Street failed to inform the medical power of attorney about any of the three neurology appointments, despite the resident's cognitive condition requiring constant supervision.
Progress notes confirmed the resident was transported to neurology appointments on the January dates. The notes stated the resident was "transferred with staff present" — but the staff member was the van driver who left immediately after drop-off.
The Corporate Coordinator acknowledged during an October 28 interview that the facility should have notified the resident's medical power of attorney about the appointments. He confirmed the resident was left at appointments without staff present.
The coordinator provided an employee statement from the van driver dated February 8 explaining what happened on January 29. The driver said he became ill after dropping the resident off, notified the facility, and left to go to the local emergency room.
The coordinator could not provide any information or statements about what happened during the January 9 appointment.
The medical power of attorney's account suggests a pattern beyond medical emergencies. She described three separate incidents over four months where the van driver failed to ensure she was present before leaving a cognitively impaired resident alone at medical appointments.
The wander guard bracelet the resident wore signals the severity of their condition. These devices are typically used for patients with dementia or other cognitive impairments who might become confused about their location or attempt to leave without supervision.
For families serving as medical power of attorney, notification about appointments is essential for coordinating care and ensuring someone can advocate for the resident during medical visits. The role typically falls to family members when residents cannot make medical decisions independently.
The facility's failure to notify the medical power of attorney left the resident vulnerable during medical appointments when they most needed an advocate present. Doctor's offices expecting family members to attend appointments with cognitively impaired patients were left scrambling to contact families when residents arrived alone.
The van driver's transfer to another position came only after the medical power of attorney complained directly to nursing leadership. The four-day delay in responding to her January 29 complaint meant the pattern continued for weeks after she raised concerns.
Federal regulations require nursing homes to immediately inform residents' doctors, family members, and legal representatives about situations affecting resident care. The requirement exists specifically to prevent scenarios like those at Willows Center, where communication breakdowns can leave vulnerable residents without proper oversight during critical moments.
The inspection found minimal harm to residents, but the violations highlight how transportation policies can affect resident safety when facilities fail to coordinate with families responsible for medical decision-making.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willows Center from 2025-10-30 including all violations, facility responses, and corrective action plans.