Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WILLOWS HEALTH CENTER

ROCKFORD, IL · 50 certified beds · Last Life Safety survey August 22, 2024

CMS Certification Number 146101 · first certified April 2006

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

33 citations — more than 87% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 11 citations; the earlier surveys in the window averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (July 2025 to October 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

5 of the 33 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 33 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	33
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 20, 2022	6
September 21, 2023	16
August 22, 2024	11

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-08-22
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-08-22
K-0363	Install corridor and hallway doors that block smoke.	2	2024-08-22
E-0039	Conduct testing and exercise requirements.	2	2024-08-22
K-0923	Have proper medical gas storage and administration areas.	2	2024-08-22
K-0712	Have simulated fire drills held at unexpected times.	2	2024-08-22
K-0324	Provide properly protected cooking facilities.	2	2023-09-21
K-0531	Have elevators that firefighters can control in the event of a fire.	1	2024-08-22

What the citations cover

Citations by CMS category

Smoke Deficiencies 13
Gas, Vacuum, and Electrical Systems Deficiencies 6
Emergency Preparedness Deficiencies 5
Egress Deficiencies 5
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	13
Gas, Vacuum, and Electrical Systems Deficiencies	6
Emergency Preparedness Deficiencies	5
Egress Deficiencies	5
Miscellaneous Deficiencies	3
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 22, 2024 — 11 citations

Citations issued on August 22, 2024
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 25, 2024)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (October 25, 2024)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (October 25, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 25, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 25, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 25, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 25, 2024)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (October 25, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 25, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 25, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (October 25, 2024)

September 21, 2023 — 16 citations

Citations issued on September 21, 2023
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (October 26, 2023)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (October 26, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 30, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (October 26, 2023)
K-0222	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.	Deficient, Provider has date of correction (October 26, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 26, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 26, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 26, 2023)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (October 26, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 26, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 26, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 26, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 26, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 26, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 26, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (October 26, 2023)

July 20, 2022 — 6 citations

Citations issued on July 20, 2022
Tag	What the surveyor checks	Status
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 9, 2022)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (September 9, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 9, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 9, 2022)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (September 9, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 9, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.