Above average — CMS composite of the measures below.
The next survey window likely opens 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 Lakeside At Willow Valley during CMS and state inspections, most recent first.
The facility did not maintain documentation verifying monthly visual inspections of exit signage over the past year. This was confirmed by the Maintenance Manager during a review and interview, indicating non-compliance with NFPA 101 standards for exit signage.
The facility failed to properly label and date food items in the walk-in freezer and did not maintain the appropriate concentration levels for sanitizing solutions, as observed during a survey. Employee E3 confirmed these deficiencies, which were not in compliance with the facility's policies on food storage and sanitation.
Failure to Document Monthly Exit Signage Inspections
Penalty
Summary
The facility failed to maintain documentation verifying that exit signage was subjected to monthly visual inspections over the previous twelve months. This deficiency was identified during a document review and interview conducted on December 18, 2024, at 10:35 AM. The Maintenance Manager confirmed the absence of documentation for these inspections, which affects the entire component of the facility's exit signage system. This lack of documentation indicates non-compliance with the requirement for continuous illumination of exit signs, as stipulated by NFPA 101 Exit Signage standards.
Plan Of Correction
Life Safety Code, NFPA 101 Exit Signage: 1. A monthly inspections of exit signage (426) has been created in the work order system to ensure all exit signage are visually inspected. 2. Team Member will visually inspect exit signage at least once per month. 3. Team Member will document completion of inspection after each occurrence. 4. The deficiency and the new process for monthly inspections (426) has been reviewed with the Lakeside Maintenance team members. 5. The corrective action will be document and monitored by our Facility Management work order system. The documentation and reports will be reviewed at Quality Assurance meeting in 2025. 6. POC date of compliance will be completed by January 31st, 2025.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper food storage and inadequate sanitation practices. During an observation, it was noted that several food items, including bags of pasta, mixed vegetables, chicken, and cookie dough, were stored in the walk-in freezer without labels or dates, contrary to the facility's policy requiring all food items to be labeled, dated, and rotated using the FIFO method. This oversight could lead to the use of outdated food, which is against the facility's food storage policy. Additionally, the facility did not maintain the appropriate concentration levels for sanitizing solutions. Observations revealed that the sanitizer concentration in a red bucket and directly from the dispenser at the three-compartment sink was 170 ppm, which did not meet the recommended range as per the facility's Sanitation Process policy. Employee E3 confirmed the deficiency in both labeling and sanitizer concentration levels, acknowledging that the observed practices did not comply with the established standards.
Plan Of Correction
Deficiency - 483.35 Dietary Services, F tag 371- Store, prepare, distribute and serve food under sanitary conditions 1. Packages of frozen vegetables, frozen chicken and fresh kale were found in the walk-in freezer and cooler out of their original boxes. They were not properly labeled with the name of the product or the received date. - All Team members will receive mandatory training on properly labeling and dating all product, especially when it is removed from its original container. - Supervisors will complete a daily walk-thru inspection for 1 quarter to assure proper labeling practices are in place. - Team Members will be held accountable for any infractions noted. - Results of the daily walk-thru inspections will be monitored for trends and reported in QI meeting. 2. Sink and Surface Cleaner and Disinfectant did not measure at the proper concentration. - EcoLab was notified immediately and the pump for the product was fixed that afternoon. The product tested at the proper concentration after it was fixed. - While the pump was not working correctly, the Team members used the Sink and Surface Cleaner and Disinfectant from another dispenser located in the pantry on the 1st floor. - All Team Members will receive mandatory training on how to properly test the concentration of the Sink and Surface Cleaner and Disinfectant. This will include the proper action plan if the concentration is not at the proper level. - Supervisors will complete a daily walk-thru inspection for 1 quarter to assure the Sink and Surface Cleaner and Disinfectant is at the proper level and that it is being properly recorded on the log sheet. - Team Members will be held accountable for any infractions noted. - Results of the daily walk-thru inspections will be monitored for trends and reported in QI meeting.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 223 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Willow Street
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glen At Willow Valley | 1.2 mi | ★★★★★ | 3 | 0 |
| Lancaster Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 7 | 0 |
| Hamilton Arms Center | 4.5 mi | ★★★★★ | 7 | 0 |
| Rose City Nursing And Rehab At Lancaster | 4.6 mi | ★★★★★ | 16 | 1 |
| Abbeyville Skilled Nursing And Rehabilitation Cent | 4.9 mi | ★★★★★ | 11 | 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.