ElderGrade

Inspection citations at Willow Terrace

61 citations on record, 3 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 5 1
2025 25 1
2024 17 1
2023 14 0
D April 30, 2026 Tag F0600 Complaint investigation

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D March 19, 2026 Tag F0684 Complaint investigation Corrected Apr 2026

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D March 19, 2026 Tag F0609 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D March 19, 2026 Tag F0607 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, potential for more than minimal harm

G March 19, 2026 Tag F0600 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident

D December 11, 2025 Tag F0835 Complaint investigation Corrected Dec 2025

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

No actual harm, potential for more than minimal harm

D December 11, 2025 Tag F0740 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, potential for more than minimal harm

D December 11, 2025 Tag F0550 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

D November 20, 2025 Tag F0692 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D August 7, 2025 Tag F0835 Complaint investigation Corrected Aug 2025

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

No actual harm, potential for more than minimal harm

J August 7, 2025 Tag F0689 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

D January 31, 2025 Tag F0880 Corrected Mar 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0847 Corrected Mar 2025

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0761 Corrected Mar 2025

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0759 Corrected Mar 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0755 Corrected Mar 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0740 Corrected Mar 2025

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0726 Corrected Mar 2025

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0710 Corrected Mar 2025

Nursing and Physician Services Deficiencies

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0698 Corrected Mar 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0692 Corrected Mar 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0689 Corrected Mar 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0686 Corrected Mar 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0685 Corrected Mar 2025

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0684 Corrected Mar 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0658 Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0609 Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0585 Corrected Mar 2025

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

D January 31, 2025 Tag F0552 Corrected Mar 2025

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

E January 31, 2025 Tag F0584 Corrected Mar 2025

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D September 11, 2024 Tag F0550 Complaint investigation Corrected Oct 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E September 11, 2024 Tag F0684 Complaint investigation Corrected Oct 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

G August 29, 2024 Tag F0600 Complaint investigation Corrected Aug 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident

D July 17, 2024 Tag F0584 Complaint investigation Corrected Aug 2024

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0684 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0908 Complaint investigation Corrected May 2024

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0840 Complaint investigation Corrected May 2024

Administration Deficiencies

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0812 Complaint investigation Corrected May 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0808 Complaint investigation Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0804 Complaint investigation Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.