All citations for Willowbrook Manor

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 Willowbrook Manor

Last standard health inspection on record

June 27, 2025

Showing 1 to 23 of 23 citations

  1. Harm to a resident

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of May 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 20, 2024).

  2. Harm to a resident

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of December 20, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 23, 2024).

  3. Harm to a resident

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Install an approved automatic sprinkler system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2023).

  6. 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 June 16, 2023. Found during a standard inspection.

    A waiver was granted (November 1, 2023).

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

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of May 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 20, 2024).

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

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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

    Health citation F-0550, Resident Rights Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    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.

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

    Health citation F-0584, Resident Rights Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Provide safe and appropriate respiratory care for a resident when needed.

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

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

  13. 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 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2023).

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

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of September 18, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (October 15, 2024).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of September 18, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (October 15, 2024).

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

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 20, 2024).

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

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of December 20, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 23, 2024).

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

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0640, Resident Assessment and Care Planning Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

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

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 1, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.