Facility profile · CCN 385201
Willowbrook Post Acute
40 federal citations on record , including 3 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $80,796.
Record summary
Federal record · Q1 202640
Total citations
31
Last 3 years
4
Actual harm+
2
Federal penalties
$80,796
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
40 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Aug 22, 2025 | F825 | Provide or get specialized rehabilitative services as required for a resident. | D | Complaint |
| Aug 22, 2025 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint |
| Aug 22, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Aug 22, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Aug 22, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Aug 22, 2025 | F761 | 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. | E | Standard |
| Aug 22, 2025 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Aug 22, 2025 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Aug 22, 2025 | F732 | Post nurse staffing information every day. | B | Standard |
| Aug 22, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Aug 22, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Aug 22, 2025 | F605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | Standard |
| Aug 22, 2025 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Aug 22, 2025 | F554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard |
| Aug 22, 2025 | F602 | Protect each resident from the wrongful use of the resident's belongings or money. | D | Complaint |
| May 17, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| May 17, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| May 17, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | E | Standard |
| May 17, 2024 | F758 | Implement 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. | D | Standard |
| May 17, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| May 17, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| May 17, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| May 17, 2024 | F688 | 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. | G | Standard |
| May 17, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| May 17, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Dec 7, 2023 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Complaint |
| Dec 7, 2023 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | E | Complaint |
| Dec 7, 2023 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | J | Complaint |
| Dec 7, 2023 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Dec 7, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | J | Complaint |
| Dec 7, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Dec 13, 2019 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Dec 13, 2019 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard |
| Dec 13, 2019 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Dec 13, 2019 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Dec 13, 2019 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Dec 13, 2019 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Dec 13, 2019 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Dec 13, 2019 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard |
| Dec 13, 2019 | F552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $80,796 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| May 17, 2024 | Fine | $61,458 | — |
| Dec 7, 2023 | Fine | $19,338 | — |
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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