Inspection visit
Inspection
Citations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
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.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0343GeneralS&S Fpotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0222GeneralS&S Epotential for 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.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the June 5, 2025 survey of WILLOWCREST HEALTH SERVICES?
This was a inspection survey of WILLOWCREST HEALTH SERVICES on June 5, 2025. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WILLOWCREST HEALTH SERVICES on June 5, 2025?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to fun..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.