Willow Creek Retirement Center

Inspection history (24)

• March 5, 2026 · D

  Citation F0584

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0584 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · D

  Citation F0656

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0656 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · D

  Citation F0690

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0690 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · D

  Citation F0867

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0867 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · F

  Citation F0880

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0880 (CMS scope/severity F: widespread, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · D

  Citation F0761

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0761 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• March 5, 2026 · D

  Citation F0558

  Federal surveyors cited this nursing home on 2026-03-05 under CMS tag F0558 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Reasonably accommodate the needs and preferences of each resident. The deficiency was recorded as corrected on 2026-04-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-03-05.GOV

• January 6, 2026 · E

  Citation F0740

  Federal surveyors cited this nursing home on 2026-01-06 under CMS tag F0740 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Ensure each resident must receive and the facility must provide necessary behavioral health care and services. The deficiency was recorded as corrected on 2026-02-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-01-06.GOV

• November 7, 2024 · E

  Citation F0880

  Federal surveyors cited this nursing home on 2024-11-07 under CMS tag F0880 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2024-12-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-11-07.GOV

• November 7, 2024 · D

  Citation F0760

  Federal surveyors cited this nursing home on 2024-11-07 under CMS tag F0760 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure that residents are free from significant medication errors. The deficiency was recorded as corrected on 2024-12-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-11-07.GOV

• November 7, 2024 · D

  Citation F0693

  Federal surveyors cited this nursing home on 2024-11-07 under CMS tag F0693 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2024-12-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-11-07.GOV

• November 7, 2024 · D

  Citation F0656

  Federal surveyors cited this nursing home on 2024-11-07 under CMS tag F0656 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The deficiency was recorded as corrected on 2024-12-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-11-07.GOV

• September 12, 2024 · G

  Citation F0689

  Federal surveyors cited this nursing home on 2024-09-12 under CMS tag F0689 (CMS scope/severity G: isolated, actual harm) for Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The deficiency was recorded as corrected on 2024-09-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-12.GOV

• May 24, 2024 · E

  Citation F0686

  Federal surveyors cited this nursing home on 2024-05-24 under CMS tag F0686 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide appropriate pressure ulcer care and prevent new ulcers from developing. The deficiency was recorded as corrected on 2024-07-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-05-24.GOV

• March 13, 2024 · D

  Citation F0686

  Federal surveyors cited this nursing home on 2024-03-13 under CMS tag F0686 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide appropriate pressure ulcer care and prevent new ulcers from developing. The deficiency was recorded as corrected on 2024-04-15. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-03-13.GOV

• March 13, 2024 · D

  Citation F0690

  Federal surveyors cited this nursing home on 2024-03-13 under CMS tag F0690 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. The deficiency was recorded as corrected on 2024-04-15. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-03-13.GOV

• August 11, 2023 · E

  Citation F0600

  Federal surveyors cited this nursing home on 2023-08-11 under CMS tag F0600 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. The deficiency was recorded as corrected on 2023-09-23. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-08-11.GOV

• August 11, 2023 · E

  Citation F0656

  Federal surveyors cited this nursing home on 2023-08-11 under CMS tag F0656 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The deficiency was recorded as corrected on 2023-09-23. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-08-11.GOV

• February 23, 2023 · D

  Citation F0677

  Federal surveyors cited this nursing home on 2023-02-23 under CMS tag F0677 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide care and assistance to perform activities of daily living for any resident who is unable. The deficiency was recorded as corrected on 2023-03-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-02-23.GOV

• February 23, 2023 · D

  Citation F0758

  Federal surveyors cited this nursing home on 2023-02-23 under CMS tag F0758 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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 l…. The deficiency was recorded as corrected on 2023-03-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-02-23.GOV

Penalties

Total fines on file: $8,018

Staffing

Latest: 4.04 nurse staffing hours per resident per day (2026-06-01)

Ownership

For profit - Limited Liability company

1. Parent organization: Briar Hill Management, LLC

   chain · PAC 7012250277