Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 235550

Willowbrook Manor

46 federal citations on record , and 5 federal enforcement actions totaling $147,365.

Record summary

Federal record · Q1 2026
46
Total citations
45
Last 3 years
3
Actual harm+
5
Federal penalties
$147,365
Total fines
2
Overall ★ rating

Most common violation categories here

Quality of Care22 Resident Rights7 Nutrition & Dietary5 Care Planning4 Medication & Pharmacy4

Most common F-tags at this facility

F6846 F8123 F6863 F6893 F5502

Citation history

46 on record
SurveyF-TagViolationSeveritySource
Nov 13, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jun 27, 2025F790Provide routine and 24-hour emergency dental care for each resident.DComplaint
Jun 27, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Jun 27, 2025F809Ensure 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.EStandard
Jun 27, 2025F692Provide enough food/fluids to maintain a resident's health.DStandard
Jun 27, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Jun 27, 2025F585Honor 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.EStandard
Jun 27, 2025F578Honor 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.DStandard
Jun 27, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EStandard
Mar 19, 2025F697Provide safe, appropriate pain management for a resident who requires such services.DComplaint
Oct 16, 2024F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.DComplaint
Sep 18, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Sep 18, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jun 4, 2024F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Jun 4, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Jun 4, 2024F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DStandard
Jun 4, 2024F760Ensure that residents are free from significant medication errors.DStandard
Jun 4, 2024F759Ensure medication error rates are not 5 percent or greater.DStandard
Jun 4, 2024F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.DStandard
Jun 4, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Jun 4, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Jun 4, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Jun 4, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Jun 4, 2024F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DStandard
Jun 4, 2024F578Honor 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.DStandard
May 23, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EComplaint
May 23, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
May 23, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
Dec 20, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Dec 20, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.GComplaint
Jun 16, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Jun 16, 2023F688Provide 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.DComplaint
Jun 16, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Jun 16, 2023F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EComplaint
Jun 16, 2023F880Provide and implement an infection prevention and control program.DStandard
Jun 16, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Jun 16, 2023F761Ensure 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.DStandard
Jun 16, 2023F695Provide safe and appropriate respiratory care for a resident when needed.EStandard
Jun 16, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Jun 16, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EStandard
Jun 16, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Jun 16, 2023F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.DStandard
Jun 16, 2023F584Honor 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.EStandard
Jun 16, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jun 16, 2023F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.DComplaint
Mar 15, 2023F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.DComplaint

Federal enforcement history

Federal regulators have imposed 5 enforcement actions against this facility, including 3 civil money penalties totaling $147,365 and 2 payment-denial actions spanning 20 days.

DateTypeFinePayment denial
May 23, 2024Fine$58,422—
May 23, 2024Payment Denial—Jun 22, 2024 · 10 days
Dec 20, 2023Fine$30,599—
Jun 16, 2023Fine$58,344—
Jun 16, 2023Payment Denial—Jul 22, 2023 · 10 days
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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