Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbrooke Court At Lanier Village Estates during CMS and state inspections, most recent first.
A facility failed to follow EBP for two residents during high-contact care. An RN provided wound care to a resident on EBP without PPE, and two CNAs provided urinary catheter care to another resident while wearing gloves but not gowns, despite EBP signage, PPE supplies outside the room, and care plans/orders requiring EBP for wound and catheter care. Staff acknowledged they had not followed the required PPE use, and the DON stated staff were expected to wear PPE for residents on EBP during high-contact care.
A resident admitted with chronic respiratory failure was observed receiving oxygen at three liters per minute instead of the prescribed two liters per minute. Staff interviews confirmed that it was the nurses' responsibility to ensure the correct flow rate, but the facility failed to adhere to the care plan and physician's orders.
A facility failed to develop a person-centered care plan for a resident with an indwelling urinary catheter, leading to inconsistencies in documentation and communication regarding the resident's catheter care. The resident, who was cognitively intact and required partial/moderate assistance, was observed performing self-catheter care without a documented care plan specifying the required assistance.
The facility failed to assess a resident with an indwelling urinary catheter for self-performance of catheter care before allowing the resident to perform the care without direct staff assistance. The resident's care plan and medical records did not specify an assessment for stand-by assist, and there were no physician's orders for self-catheter care. Interviews with staff confirmed the lack of necessary assessment and documentation.
The facility failed to follow the physician's order for oxygen therapy and did not ensure the oxygen concentrator had a filter while in use for a resident. The resident was observed using an oxygen concentrator set at three liters per minute instead of the ordered two liters per minute, and the concentrator was missing its filter. Staff were unsure about the schedule for cleaning or replacing the filters and where this task was documented.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) for two residents while providing high-contact care. The facility policy, Guidelines for Isolation Precautions, required staff to wear gowns and gloves for high-contact care activities such as wound care, urinary catheter care, and hygiene care. R6 was care planned for EBP related to wound care, and signage outside the room directed staff to wear PPE. During an observation of wound care, an RN provided wound care to R6 without using PPE in accordance with EBP. The RN later acknowledged that she did not don PPE before the wound care and stated it was an oversight. The DON stated it was her expectation that staff wear PPE for residents on EBP when providing high-contact care, including wound care. R4's record showed diagnoses including urinary retention and renal insufficiency, dependence on staff for lower body dressing and toileting, substantial to maximal assistance for personal hygiene and transfers, and an indwelling urinary catheter. The care plan included EBP and indwelling catheter care, and physician orders directed EBP twice daily for prevention of transmission of MDRO infections and catheter care twice daily. During observation, two CNAs provided urinary catheter care while wearing gloves but not gowns, despite EBP signage and a PPE cart outside the room instructing staff to don gowns and gloves. One CNA stated she should have worn a gown and had forgotten, while the other stated she normally did not wear a gown for catheter care or ADL care and thought gloves were all that was needed. The DON stated nursing staff had received education on EBP and expected them to follow EBP during high-contact care.
Failure to Implement Oxygen Therapy Interventions
Penalty
Summary
The facility failed to implement interventions for oxygen therapy for a resident (R290) receiving oxygen therapy. The resident was admitted with diagnoses including dyspnea, interstitial pulmonary disease, chronic respiratory failure with hypoxia, and syncope and collapse. The care plan indicated that the resident should receive oxygen via nasal cannula at two liters per minute, initiated on 4/19/2024. However, observations on multiple occasions revealed that the resident was receiving oxygen at three liters per minute, contrary to the physician's orders. Licensed Practical Nurse (LPN) AA confirmed that the oxygen flow meter was set at three liters per minute and acknowledged that it was the nurses' responsibility to ensure the flow meter was set according to the physician's orders. Interviews with various staff members, including the Director of Nursing (DON), Registered Nurse (RN) Care Coordinator BB, RN CC, RN DD, and the Assistant Director of Nursing (ADON), revealed that the facility's policy required the nursing staff to monitor and verify the concentrator flow rate as per the physician's orders. The staff also indicated that the care plan should be reviewed and updated regularly to ensure it reflects the resident's current needs and interventions. Despite these expectations, the facility failed to adhere to the care plan and physician's orders, resulting in the resident receiving an incorrect oxygen flow rate.
Failure to Develop Person-Centered Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a person-centered care plan with interventions that addressed performing catheter care for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and required partial/moderate assistance during self-care, was observed performing self-catheter care in the shower with a CNA standing by to observe and verify the care was completed correctly. However, the care plan did not include specific interventions for catheter care, and there was no documentation indicating the type of assistance required for catheter care in the electronic medical record (EMR). Interviews with staff revealed inconsistencies and gaps in the documentation and communication regarding the resident's catheter care. The CNA stated that she knew the resident required stand-by assistance for catheter care based on her personal knowledge of the resident, but this information was not documented in the EMR. The LPN and RN Care Coordinator confirmed that there was no care plan developed for the resident to self-perform catheter care, and the RN Care Coordinator was unaware that the resident was performing self-catheter care. The Director of Nursing (DON) stated that the expectation was for the Care Coordinator to develop and revise care plans based on new orders entered into the resident's medical records. However, the RN Care Coordinator, who had only been working at the facility for a few days, had not developed a care plan for the resident's self-catheter care. This lack of a comprehensive and documented care plan for catheter care placed the resident at risk for medical complications and unmet needs.
Failure to Assess Resident for Self-Performance of Catheter Care
Penalty
Summary
The facility failed to assess a resident with an indwelling urinary catheter for self-performance of catheter care before allowing the resident to perform the care without direct staff assistance. The facility's policy on catheter care requires an assessment to prevent contamination and catheter-associated urinary tract infections. However, there was no evidence in the electronic medical record (EMR) that such an assessment had been completed for the resident, who was observed performing self-catheter care in the shower with only stand-by assistance from a Certified Nursing Assistant (CNA). The resident's care plan, Minimum Data Set (MDS) assessment, and task list did not specify that the resident was assessed for stand-by assist for catheter care, and there were no physician's orders for the resident to perform self-catheter care. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and a Registered Nurse (RN) Care Coordinator, confirmed that the necessary assessment and documentation were not completed. The DON stated that the expectation was for the nurse to call the physician to request an order for self-care and perform an assessment to verify the resident's ability to perform self-catheter care. The RN Care Coordinator also mentioned that the nurse should educate the resident on signs and symptoms of infection and proper catheter care performance before notifying the physician to obtain an order. Despite these expectations, the facility did not provide a policy related to resident assessment for self-catheter care upon request.
Failure to Follow Physician's Order for Oxygen Therapy and Ensure Proper Equipment Maintenance
Penalty
Summary
The facility failed to follow the physician's order for oxygen therapy and did not ensure the oxygen concentrator had a filter while in use for one resident. The resident, who was admitted with diagnoses including dyspnea, interstitial pulmonary disease, and chronic respiratory failure with hypoxia, was observed using an oxygen concentrator set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the oxygen concentrator was missing its filter, which is required to be cleaned or replaced weekly according to the facility's policy. Observations and interviews revealed that the resident had been using the oxygen concentrator continuously since admission, and the flow meter was consistently set at three liters per minute. The Licensed Practical Nurse (LPN) confirmed the discrepancy in the oxygen flow rate and the missing filter. The LPN was unsure about the exact schedule for cleaning or replacing the filters and where this task was documented, indicating a lack of adherence to the facility's protocols. The Director of Nursing (DON) confirmed the physician's order for oxygen at two liters per minute and acknowledged that the admitting nurse should ensure the concentrator has a clean filter before use. The DON also stated that oxygen tubing should be changed weekly, and each component should be labeled with the date it was changed. The DON expected staff to verify the flow meter rate during nursing rounds and ensure it matched the physician's order. The failure to follow these procedures led to the deficiency observed by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Limestone | 5 mi | ★★★★★ | 0 | 0 |
| New Horizons Limestone | 5.6 mi | ★★★★★ | 9 | 0 |
| Bell Minor Home, The | 6.3 mi | ★★★★★ | 1 | 0 |
| Chelsey Park Health And Rehabilitation | 11.6 mi | ★★★★★ | 1 | 0 |
| Gold City Health And Rehab | 12.3 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.