Facility profile · CCN 265607
Willowcreek Wellness & Rehabilitation
85 federal citations on record , including 5 at the Immediate Jeopardy level, and 4 federal enforcement actions totaling $97,920.
Record summary
Federal record · Q1 202685
Total citations
38
Last 3 years
7
Actual harm+
4
Federal penalties
$97,920
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
85 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Jan 7, 2026 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint |
| Nov 18, 2025 | F740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D | Complaint |
| Nov 18, 2025 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Complaint |
| Jun 20, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Complaint |
| Jun 20, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | Complaint |
| Jun 20, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| May 13, 2025 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| May 13, 2025 | F585 | 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. | D | Complaint |
| Mar 4, 2025 | F865 | Have a plan that describes the process for conducting QAPI and QAA activities. | E | Complaint |
| Mar 4, 2025 | F740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | J | Complaint |
| Mar 4, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Mar 4, 2025 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Mar 4, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Mar 4, 2025 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Complaint |
| Oct 22, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint |
| Oct 22, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Oct 3, 2024 | F808 | 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. | D | Complaint |
| Oct 3, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Aug 14, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | F | Complaint |
| Aug 14, 2024 | F808 | 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. | D | Complaint |
| Aug 14, 2024 | F584 | 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. | E | Complaint |
| Aug 14, 2024 | F810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Standard |
| Aug 14, 2024 | F809 | 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. | E | Standard |
| Aug 14, 2024 | F700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | E | Standard |
| Aug 14, 2024 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E | Standard |
| Aug 14, 2024 | F693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | E | Standard |
| Aug 14, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Aug 14, 2024 | F691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D | Standard |
| Aug 14, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Aug 14, 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. | D | Standard |
| Aug 14, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Aug 14, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Standard |
| Aug 14, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Aug 14, 2024 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | C | Standard |
| Aug 14, 2024 | F568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | F | Standard |
| Aug 14, 2024 | F554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard |
| Jul 24, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jul 24, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Mar 8, 2023 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint |
| Feb 2, 2022 | F924 | Put firmly secured handrails on each side of hallways. | E | Standard |
| Feb 2, 2022 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Feb 2, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Feb 2, 2022 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard |
| Feb 2, 2022 | F803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | J | Standard |
| Feb 2, 2022 | 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 |
| Feb 2, 2022 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Feb 2, 2022 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Feb 2, 2022 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Feb 2, 2022 | F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | E | Standard |
| Feb 2, 2022 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Feb 2, 2022 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Feb 2, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard |
| Feb 2, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Feb 2, 2022 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Standard |
| Feb 2, 2022 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | E | Standard |
| Feb 2, 2022 | F586 | Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | D | Standard |
| Feb 2, 2022 | F585 | 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. | D | Standard |
| Feb 2, 2022 | F584 | 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. | E | Standard |
| Feb 2, 2022 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard |
| Feb 2, 2022 | F567 | Honor the resident's right to manage his or her financial affairs. | E | Standard |
| Feb 2, 2022 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Standard |
| Feb 2, 2022 | F554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard |
| Feb 5, 2020 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Feb 5, 2020 | F849 | 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. | D | Standard |
| Feb 5, 2020 | F814 | Dispose of garbage and refuse properly. | E | Standard |
| Feb 5, 2020 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Feb 5, 2020 | F790 | Provide routine and 24-hour emergency dental care for each resident. | D | Standard |
| Feb 5, 2020 | 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 |
| Feb 5, 2020 | F759 | Ensure medication error rates are not 5 percent or greater. | E | Standard |
| Feb 5, 2020 | 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. | E | Standard |
| Feb 5, 2020 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Standard |
| Feb 5, 2020 | F730 | Observe each nurse aide's job performance and give regular training. | E | Standard |
| Feb 5, 2020 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E | Standard |
| Feb 5, 2020 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E | Standard |
| Feb 5, 2020 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard |
| Feb 5, 2020 | 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. | D | Standard |
| Feb 5, 2020 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Standard |
| Feb 5, 2020 | F679 | Provide activities to meet all resident's needs. | E | Standard |
| Feb 5, 2020 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard |
| Feb 5, 2020 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Standard |
| Feb 5, 2020 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Feb 5, 2020 | F584 | 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. | E | Standard |
| Feb 5, 2020 | F576 | Ensure residents have reasonable access to and privacy in their use of communication methods. | E | Standard |
| Feb 5, 2020 | F569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | E | Standard |
| Feb 5, 2020 | F558 | Reasonably accommodate the needs and preferences of each resident. | E | Standard |
Federal enforcement history
Federal regulators have imposed 4 enforcement actions against this facility, including 2 civil money penalties totaling $97,920 and 2 payment-denial actions spanning 41 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Jun 20, 2025 | Fine | $24,845 | — |
| Mar 4, 2025 | Fine | $73,075 | — |
| Mar 4, 2025 | Payment Denial | — | Mar 7, 2025 · 35 days |
| Aug 14, 2024 | Payment Denial | — | Nov 14, 2024 · 6 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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