All citations for Willow Haven Health and Rehab, LLC

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Willow Haven Health and Rehab, LLC

Last standard health inspection on record

August 1, 2025

Showing 1 to 25 of 36 citations

  1. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  2. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  3. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of November 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 6, 2020).

  4. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0521, Services Deficiencies. Inspection of November 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 10, 2020).

  5. No harm, with potential for more than minimal harm

    Conduct risk assessment and an All-Hazards approach.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  6. No harm, with potential for more than minimal harm

    Address subsistence needs for staff and patients.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  7. No harm, with potential for more than minimal harm

    Establish policies and procedures including evacuation.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0020, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  8. No harm, with potential for more than minimal harm

    Establish policies and procedures for volunteers.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0024, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  9. No harm, with potential for more than minimal harm

    Develop a communication plan.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0029, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  10. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  11. No harm, with potential for more than minimal harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0232, Egress Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  12. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  13. No harm, with potential for more than minimal harm

    Install a fire alarm system that can be heard throughout the facility.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0341, Smoke Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  14. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  15. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  16. No harm, with potential for more than minimal harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  17. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 19, 2023).

  18. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  19. No harm, with potential for more than minimal harm

    Implement emergency and standby power systems.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0041, Emergency Preparedness Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  20. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  21. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  22. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0521, Services Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  23. No harm, with potential for more than minimal harm

    Have power receptacles that are properly grounded.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0912, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of June 21, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 9, 2022).

  24. No harm, with potential for more than minimal harm

    Establish roles under a Waiver declared by secretary.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of November 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2020).

  25. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of November 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 8, 2020).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.