Willowcrest Health Services

Penalties

• Mar 29, 2024 — Fine ($21,285)

Inspection findings

1. Jun 5, 2025 Fire Safety · 23 findings
   • Not serious Scope/severity F

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     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.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Apr 24, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

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

     Corrected Jul 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Jul 5, 2025 · CMS fire safety

2. Mar 5, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Mar 31, 2025 · CMS health inspection

3. Oct 14, 2024 Health · 1 finding
   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Nov 12, 2024 · CMS health inspection

4. Mar 29, 2024 Health · 27 findings
   • Not serious Scope/severity B

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Apr 26, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Apr 26, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0694 Quality of Life and Care Deficiencies

     Provide for the safe, appropriate administration of IV fluids for a resident when needed.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0730 Nursing and Physician Services Deficiencies

     Observe each nurse aide's job performance and give regular training.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Apr 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Sep 30, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Sep 30, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0233 Egress Deficiencies

     Install resident room doors of proper design and width.

     Corrected Apr 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

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

     Corrected Apr 26, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

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

     Corrected Jul 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0531 Services Deficiencies

     Have elevators that firefighters can control in the event of a fire.

     Corrected Aug 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Apr 26, 2024 · CMS fire safety

5. Jan 12, 2023 Health · 13 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jul 6, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

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

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jul 6, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 06/29/2017
• HOEHN, JEFFREY — w-2 managing employee, NOT APPLICABLE, since 06/29/2017
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 06/29/2017
• MILLS, DAVID — 5% or greater indirect ownership interest, 20%, since 06/29/2017
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• NSHF OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 07/24/2017