Willard Care Center: Wrong Medication Dosing Frequency - MO
The resident had been discharged from a hospital with an order for ferrous sulfate 142 mg every Friday, to be given with vitamin C. When staff entered the order into the facility's physician order sheet, it went in as ferrous sulfate 324 mg, one-half tablet by mouth every Friday. That's a different dose than what the hospital ordered. But the frequency is where the administration broke down entirely. The medication ended up scheduled daily in the electronic medication administration record.
From that point forward, staff gave the iron supplement every day. The eMAR showed no gaps. Nobody had flagged it.
The Director of Nursing reviewed the records during the inspection and confirmed it herself: the ferrous sulfate was scheduled daily, and staff documented giving it daily. The eMAR is built so that medications appear on screen when they are due. If the Friday-only frequency had been entered correctly, staff would have seen a message on every other day reading "No Administration Available," along with the date and time of the last dose. That message never appeared because the order had been entered wrong.
The facility's system works like this: a charge nurse inputs medication orders into the physician order sheet, and the eMAR populates automatically from there. The physician then approves the order, and the pharmacy reviews the medication list. Somewhere in that chain, a once-weekly iron supplement became a daily one, and the physician approval and pharmacy review did not catch it.
During an interview on October 31, the Administrator acknowledged the ordering frequency is not prominently displayed on the administration screen that certified medication technicians and nurses actually see when they are giving medications. Staff looking at that screen are focused on the dosing time and on whether the system shows a message indicating the medication is not yet due. The frequency information is present, the Administrator said, but it sits off to the side, separate from the primary display.
"The ordered frequency is not very prominent on the administration screen," the Administrator said, "and CMTs might not notice that information."
That is a notable thing for an administrator to say. The facility's own medication system has a known design limitation, the person running the facility is aware of it, and a resident still ended up receiving a medication at six times the intended rate.
Iron supplements are not benign at elevated doses. Daily iron can cause gastrointestinal distress, constipation, and nausea. The inspection cited the deficiency at a level of minimal harm or potential for actual harm, meaning inspectors did not document that the resident suffered a serious injury. But the resident was given a medication incorrectly, repeatedly, over a period long enough that the eMAR showed a consistent daily administration record with no gaps.
The Administrator said staff are supposed to follow the physician order sheet for medication administration. The charge nurse is responsible for entering orders, or the DON can step in if the nurse doesn't have time. The eMAR is supposed to reflect whatever is in the order sheet. In this case, what was in the order sheet was wrong, and the eMAR faithfully reproduced that error every day.
The inspection was conducted on October 31, 2025, in response to a complaint.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willard Care Center from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
WILLARD CARE CENTER in WILLARD, MO was cited for violations during a health inspection on October 31, 2025.
The resident had been discharged from a hospital with an order for ferrous sulfate 142 mg every Friday, to be given with vitamin C.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.