Data from CMS, updated September 1, 2026. How we rate · Report a correction
CMS file
CCN 385201
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS has turned on the abuse icon. The September 2026 Technical Users' Guide applies that icon for abuse tags F600, F602, or F603: a citation at scope and severity G or higher on the most recent standard survey or on a complaint or focused infection-control survey in the past 12 months, or a repeat citation at D or higher across the recent windows described in the guide. While the icon is on, the health inspection rating is capped at two stars.
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
Adjusted total nurse hours: 5.30. Adjusted RN hours: 0.61. Case-mix total: 3.64. Case-mix index: 1.330.
Total nursing staff turnover: 52.9%. RN turnover: 54.5%. Administrators who left: 1.
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS reports 2 fines totaling $80,796, and 0 payment denials.
| Date | Type | Amount or days |
|---|---|---|
| May 17, 2024 | Fine | $61,458 |
| December 7, 2023 | Fine | $19,338 |
Cycle 1 standard survey: August 22, 2025. Health deficiencies counted in cycle 1: 17. Cycle 1 total health score: 84.
Cycle 2 standard survey: May 17, 2024. Cycle 2/3 health deficiencies: 17. Total weighted health survey score: 139.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
The Health Deficiencies file lists 43 citations for this home, including 3 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Past Non-Compliance · March 30, 2026 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 6, 2026 |
| F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 13, 2026 |
15 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 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. Nursing and Physician Services Deficiencies · Complaint survey · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 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. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 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. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
| F602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Past Non-Compliance · November 21, 2024 |
| F732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Standard survey · Cycle 1 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · September 29, 2025 |
10 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| 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. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · June 20, 2024 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 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. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 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. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2024 |
6 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · December 8, 2023 |
| F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · December 8, 2023 |
| F658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · December 8, 2023 |
| F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2023 |
| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2023 |
| F610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2023 |
9 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 10, 2020 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Willowbrook Post Acute has an overall rating of 1 out of 5. The health inspection rating is 1, staffing is 4, and the quality measure rating is 3.
The Health Deficiencies file lists 43 health citations for this home. 3 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).
CMS reports 5.03 total nurse hours per resident per day, including 0.58 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.