Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbrook Healthcare during CMS and state inspections, most recent first.
Failure to Assess and Reevaluate Physical Restraints: Three residents were observed using seat belts and gait belts on motorized wheelchairs without documented restraint assessments, re-evaluations, or physician orders. One resident with hemiplegia and another with NSTEMI and muscle weakness were both cognitively intact and seated with seat belts, while a third resident with paraplegia and Alzheimer's disease had gait belts wrapped around her legs and feet. The DON stated the gait belts were not considered restraints, but also acknowledged no assessments had been completed for the devices.
Improper Storage of Refrigerated Medications: Medications in the North Hall med room refrigerator, including a COVID-19 vaccine, insulin pens, Ozempic, and TB serum, were stored in the refrigerator door rather than in a protected location. Staff interviews confirmed nursing was responsible for medication storage, and the LPN, DON, and Administrator all stated the door was not an appropriate storage area because of temperature fluctuations and light exposure that could affect medication effectiveness.
Failure to provide bed-hold and transfer notices affected two residents. One resident with chest pain and intact cognition was sent to the hospital without documentation of receiving a Bed Hold or Transfer Notice, and a second resident with severe cognitive impairment was transferred to the ER after an unwitnessed fall without a bed-hold/transfer notice; the family representative reported not receiving notice by mail. Staff interviews showed inconsistent understanding of how the notice was to be issued and mailed.
A facility failed to ensure MDS assessments accurately reflected resident status for three residents regarding physical restraints. The MDS Coordinator was responsible for completing assessments per the RAI Manual, but the MDS did not code the residents for physical restraints. The DON stated the residents were not being restrained against their will, and the Administrator stated he expected all residents to be assessed and coded correctly on the MDS.
Failure to care plan and order gait belt use: A cognitively intact resident with NSTEMI, muscle weakness, and OA was observed using a gait belt wrapped around his legs while seated in a motorized wheelchair. The gait belt was not addressed in the care plan, there was no MD order for its use, and the EMR lacked skin assessment documentation for the seat belt and gait belt. The DON and Administrator stated the device should have been ordered and assessed for safety.
A facility failed to provide respiratory care according to physician orders and its oxygen policy for two residents. One resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered, and staff were unsure how often concentrators should be checked. Another resident with COPD and CAD had oxygen tubing and distilled water that were not dated, and staff gave inconsistent statements about tubing and water changes.
Hair Not Fully Covered During Food Service: An observation in the kitchen found a dietary aide with about four inches of hair hanging out of the hair net while leaning over the steam table. The facility policy required dietary staff to wear hair restraints so hair did not contact food, and the dietary aide stated she did not know and acknowledged hair could fall in the food. The DM and Administrator stated hair was expected to be fully covered.
The facility failed to follow infection control policies for three residents. A KMA administered eye drops without hand hygiene or gloves and handled another resident’s pills with an ungloved hand before giving the remaining medication. During wound care, an ADON/IP washed scissors in the sink and placed used scissors and tape back into the treatment cart drawer. The DON and Administrator stated staff were expected to follow infection control policies, including proper hand hygiene, glove use, and equipment handling.
Failure to Assess and Reevaluate Physical Restraints
Penalty
Summary
The facility failed to ensure residents were free from physical restraints and failed to document assessments and ongoing re-evaluations for restraint use for 3 sampled residents. The facility policy stated restraints were to be used only for the resident’s safety and well-being after other alternatives failed, only for medical symptoms, and only after a pre-restraint assessment and physician order with consent. However, the electronic health records for the sampled residents did not contain assessments or re-evaluations related to the restraint devices, and there were no physician orders for the devices observed in use. R10 was admitted with hemiplegia and hemiparesis following cerebral infarction, unspecified muscle spasm, and congestive heart failure. His quarterly MDS showed a BIMS score of 15 out of 15. On observation, he was sitting in his motorized wheelchair with a seat belt securing him. During interview, he stated he had difficulty using his left hand and it could be difficult for him to remove the self-releasing seat belt. He said staff removed the seat belt at his request and when he received care, and that no one checked whether he could fasten or unfasten it. There was no order for the self-releasing seat belt and no related assessment or re-evaluation in the EHR. R41 was admitted with NSTEMI myocardial infarction, muscle weakness, and primary osteoarthritis, and his quarterly MDS showed a BIMS score of 15 out of 15. He was observed in his motorized wheelchair with a seat belt securing him. He stated he could release the seat belt, but sometimes forgot how to unsnap the gait belt on his legs. He also stated he had never been assessed by a nurse or doctor for the gait belt. R38 was admitted with paraplegia, left shoulder pain, and Alzheimer's disease, and her quarterly MDS showed a BIMS score of 15 out of 15. She was observed in her motorized wheelchair with one gait belt wrapped around her legs and another around both feet and the foot pedals. She stated she could remove the belt around her legs but could not reach the belt around her feet, and she said she had never received an assessment or review from the doctor concerning the gait belts. The DON stated the gait belts were not considered physical restraints, but also stated there were no assessments completed for the gait belts or self-releasing seat belts.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to ensure medications in the North Hall medication room were stored in a manner that protected them from temperature changes, humidity changes, and exposure to light. During observation, the refrigerator in that medication room was found to contain one COVID-19 vaccine, one Solostar insulin pen, one Ozempic pen, one insulin glargine pen, and one vial of tuberculin (TB) serum stored in the refrigerator door. The report also reviewed the facility’s policy on medication storage, CDC guidance on refrigerated vaccines, the manufacturer’s instructions for Ozempic, and ADA guidance on insulin storage, all of which addressed proper storage conditions and avoiding exposure to light and unstable temperatures. During interviews, KMA 1 stated nursing staff were responsible for putting away medications delivered to the facility, including refrigerated medications. LPN 4 stated nurses managed the medication refrigerator and acknowledged the refrigerator door was not a proper storage location because of temperature changes and light exposure that could affect contamination or effectiveness. The DON/IP stated medications should not be stored in the refrigerator door because of unstable temperatures and constant opening and closing, and the Administrator stated it was not appropriate to store medications in the refrigerator door because of potential contamination and weakened efficacy.
Failure to Provide Bed-Hold and Transfer Notices
Penalty
Summary
The facility failed to notify residents and their representatives in writing, in a language and manner they understood, of transfers to the emergency department and the reasons for the move, and failed to provide written information about the duration of the state bed-hold policy for 2 of 3 sampled residents, R6 and R7. The facility’s policy titled, Holding Bed Space, revised 2001, stated residents should be informed upon admission and prior to transfer for hospitalization or therapeutic leave of the bed-hold policy. Review of the records showed that R6 was admitted with diagnoses including type 2 diabetes mellitus with other specified complications, hyperlipidemia, and unspecified bladder disorder, and had a BIMS score of 14 out of 15, indicating he was cognitively intact. On [DATE], RN 2 documented that R6 had chest pain and chose to go to the hospital, but there was no documentation that he received a Bed Hold or Transfer Notice, and R6 stated he was not given any papers when he went to the hospital for chest pain. R7 was admitted with diagnoses including a displaced fracture of the lower end of the left humerus, unspecified fall, and type 2 diabetes mellitus without complications, and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. On 04/29/2026, LPN 5 found R7 on the bathroom floor after her alarm sounded; she was lying on her right side holding her left arm and wrist, and she reported she had fallen and bent her left wrist back, with swelling and pain noted. The next day, R7 was sent to the local emergency room after an unwitnessed fall, but there was no bed hold or transfer notice documented before the transfer. R7’s family representative stated she did not receive any bed hold/transfer notice by mail. The BOM stated she used Document Management to create the Bed Hold, would have the resident sign if cognitively intact, and would call or email the family representative if the resident was not cognitively intact; the DON stated she was not very well-versed with the Bed Hold or Transfer Notice and said families should be notified and the bed hold should be mailed, while the Administrator stated the notice should be given to residents as they were leaving and mailed to family representatives.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility failed to ensure MDS assessments accurately reflected resident status for three sampled residents, R10, R38, and R41, related to physical restraints. Review of the facility’s MDS Coordinator job description showed responsibilities for scheduling, completing, and submitting MDS assessments in accordance with the RAI Manual and state and federal regulations. However, the facility’s MDS dated [DATE] at 10:57 AM did not code R10, R38, and R41 for physical restraints. During interview, the DON stated these residents would not have been coded for physical restraints because they were not being restrained against their will and said the facility coded residents per the RAI Manual. The Administrator stated he did not know why those residents would be considered to have a physical restraint and expected all residents to be assessed and coded correctly on the MDS.
Failure to Care Plan and Order Gait Belt Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with identified medical, nursing, mental, and psychosocial needs. Resident 41 was admitted with NSTEMI myocardial infarction, muscle weakness, and primary osteoarthritis, and the quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact. During observation, the resident was sitting in a motorized wheelchair with a seat belt securing him to the chair, and he was also wearing a gait belt wrapped around his legs that was not ordered or addressed in the comprehensive care plan. Review of the resident’s care plan showed no documentation for the gait belt use, and the physician orders contained no order for the resident to wear a gait belt around his legs. The EMR also had no documentation of skin assessments for the self-releasing seat belt or gait belt. The DON stated the gait belt should have been added to the care plan and assessed to ensure it was the correct alternative for the resident’s medical conditions, and that residents using a gait belt around their legs and feet should have a physician’s order. The Administrator stated residents with a gait belt around their legs and feet should have a doctor’s order and be assessed to ensure the device was safe for daily use.
Oxygen Therapy Not Provided According to Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders and its own oxygen policy for 2 of 16 sampled residents. One resident was admitted with diagnoses including COPD and acute and chronic respiratory failure with hypoxia and had a physician order for oxygen at 2 LPM via nasal cannula. On observation, the resident was receiving oxygen through a nasal cannula with the concentrator set above the ordered rate, first at 3 LPM and later at 2.5 LPM. During interview, an LPN acknowledged the concentrator was set above the ordered amount and stated she did not know how often oxygen concentrators were supposed to be checked. Another LPN and the Administrator stated staff were expected to follow physician orders for oxygen. A second resident, admitted with diagnoses including COPD and coronary artery disease, had oxygen tubing last changed on the treatment administration record, but on observation the oxygen tubing and distilled water were not dated. Staff interviews showed uncertainty about who was responsible for dating and changing the tubing and water, and differing statements about how often the tubing should be changed. The DON and Administrator stated they expected staff to follow the oxygen policy, and both acknowledged there could be an infection issue if the tubing and water were not changed as directed.
Hair Not Fully Covered During Food Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when Dietary Aide 2 was observed in the kitchen with approximately four inches of hair hanging out of the hair net on both sides of the front of the head while leaning over the steam table. The facility policy titled, Food Preparation and Service, revised July 2014, required dietary staff to wear hair restraints so that hair did not contact food. During the observation, Dietary Aide 2 stated she did not know and acknowledged that hair could fall in the food. The Dietary Manager stated the importance of keeping hair in the hair net was so hair did not get in the food, and the Administrator stated he expected dietary staff to have their hair completely covered.
Failure to Follow Infection Control Practices During Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow its infection prevention and control policies for 3 of 17 sampled residents, including R3, R16, and R47. The facility policies required hand hygiene before and after resident contact, before nursing procedures, after removing gloves, and after contact with potentially contaminated surfaces. The policies also required cleaning and disinfection of equipment and surfaces before and after resident use, and stated reusable resident care equipment must be decontaminated and/or sterilized between residents according to facility protocols. For R47, who was admitted with mild cognitive impairment, chronic kidney disease, and hyperlipidemia, observation showed a KMA entered the room and administered eye drops without performing hand hygiene and without donning gloves. For R3, who was admitted with type 2 diabetes, epilepsy, and autoimmune disorders, observation showed a KMA prepared medications, obtained the resident’s blood pressure, then poured all medications into her ungloved hand, removed and discarded one medication, placed the remaining medications back into the cup, and administered them to the resident. During interview, the KMA stated she should have sanitized her hands and donned gloves before administering the eye drops and stated that dumping the pills into her ungloved hand contaminated them. For R16, observation showed the ADON/IP finished applying a dressing to the resident’s left foot, washed the scissors in the sink, then picked up the tape used during the dressing change and placed both the scissors and tape on top of the treatment cart and into the top drawer. During interview, the ADON/IP stated she washed the scissors between patients with soap and water and put the tape back in the treatment cart. The DON stated scissors should be cleaned with Sani-wipes and tape should be thrown away if placed on the bedside table, and the Administrator stated he expected staff to follow the policy and prevent transmission of infection.
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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 Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison Nursing And Rehabilitation Center | 14.1 mi | ★★★★★ | 20 | 0 |
| Edgemont Healthcare | 14.3 mi | ★★★★★ | 0 | 0 |
| Bourbon Heights Nursing Home | 14.5 mi | ★★★★★ | 8 | 0 |
| Robertson County Health Care Facility | 15.3 mi | ★★★★★ | 0 | 0 |
| Cedar Ridge Health Campus | 15.7 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.