ElderGrade

Inspection citations at Willowbrook Manor

46 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 3 0
2025 10 0
2024 18 1
2023 15 2
D March 16, 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 February 5, 2026 Tag F0695 Complaint investigation Corrected Mar 2026

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

E February 5, 2026 Tag F0550 Complaint investigation Corrected Mar 2026

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 13, 2025 Tag F0684 Complaint investigation Corrected Dec 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 June 27, 2025 Tag F0790 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

No actual harm, potential for more than minimal harm

D June 27, 2025 Tag F0692 Corrected Jul 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 June 27, 2025 Tag F0684 Corrected Jul 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 June 27, 2025 Tag F0578 Corrected Jul 2025

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

E June 27, 2025 Tag F0812 Corrected Jul 2025

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

E June 27, 2025 Tag F0809 Corrected Jul 2025

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

No actual harm, potential for more than minimal harm

E June 27, 2025 Tag F0585 Corrected Jul 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

E June 27, 2025 Tag F0550 Corrected Jul 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 March 19, 2025 Tag F0697 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D October 16, 2024 Tag F0694 Complaint investigation Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D September 18, 2024 Tag F0690 Complaint investigation Corrected Oct 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D September 18, 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

D June 4, 2024 Tag F0849 Corrected Jul 2024

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0804 Corrected Jul 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

D June 4, 2024 Tag F0760 Corrected Jul 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0759 Corrected Jul 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0740 Corrected Jul 2024

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 June 4, 2024 Tag F0686 Corrected Jul 2024

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 June 4, 2024 Tag F0684 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 June 4, 2024 Tag F0677 Corrected Jul 2024

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0656 Corrected Jul 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0604 Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

No actual harm, potential for more than minimal harm

D June 4, 2024 Tag F0578 Corrected Jul 2024

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

E June 4, 2024 Tag F0812 Corrected Jul 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 May 23, 2024 Tag F0600 Complaint investigation Corrected Jun 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.

No actual harm, potential for more than minimal harm

E May 23, 2024 Tag F0689 Complaint investigation Corrected Jun 2024

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

G May 23, 2024 Tag F0686 Complaint investigation Corrected Jun 2024

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D December 20, 2023 Tag F0689 Complaint investigation Corrected Jan 2024

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

G December 20, 2023 Tag F0684 Complaint investigation Corrected Jan 2024

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D June 16, 2023 Tag F0880 Corrected Aug 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D June 16, 2023 Tag F0761 Corrected Aug 2023

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 June 16, 2023 Tag F0690 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D June 16, 2023 Tag F0689 Corrected Aug 2023

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 June 16, 2023 Tag F0688 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D June 16, 2023 Tag F0640 Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

No actual harm, potential for more than minimal harm

E June 16, 2023 Tag F0695 Corrected Aug 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

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.