Institution Workup · one facility, fully worked
Willow Creek Rehabilitation & Care Center
4400 Harvest Lane, Sample City, IL 62999 · Sample County · CCN 14E999 · Legal business name: Willow Creek SNF Operator, LLC
SNAPSHOT This page is a dated snapshot and is superseded by the live page.
Citation history
Sixteen health citations across seven surveys (2023-06-08 → 2026-02-12), five cited at scope/severity G or above, meaning actual-harm-or-above band, including one at J (immediate jeopardy) on the 2025-10-21 complaint survey. These do not characterize conduct. They are categories of the types of conduct observed.
| Isolated | Pattern | Widespread | |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J×1 | K | L |
| Actual harm that is not immediate jeopardy | G×4 | H | I |
| No actual harm · potential for more than minimal harm | D×6 | E×4 | F×1 |
| No actual harm · potential for minimal harm | A | B | C |
G or above = "actual harm or above." 5 of 16 citations sit in that band. Letters are CMS's published scope/severity grid; counts are this facility's, last 3 inspection cycles.
How to read this section
Each row states the F-tag, CMS's deficiency category, the scope/severity letter as surveyed, and the correction record (plan of correction, revisit). Repeat citations under the same F-tag are flagged. They drive the §05 determination.
One citation is under informal dispute (IDR); it is displayed with its filing date, exactly as we show every dispute. Outcomes post at the following CMS release.
"cited at scope/severity G": the record's phrase, and ours. We recount; we do not characterize.| F-tag | Deficiency category (CMS) | Scope/severity | Correction record |
|---|---|---|---|
| SURVEY 2026-02-12 · STANDARD RECERTIFICATION · CMS-2567 ↗ | |||
| F-725Repeat ×3 | Sufficient nursing staff: provide services by sufficient numbers of personnel on a 24-hour basis | EPattern · no actual harm | PoC accepted 2026-03-15 corrected 2026-04-08 · revisit |
| F-686 | Treatment/services to prevent or heal pressure ulcers | DIsolated · no actual harm | IDR pending · filed 2026-03-02 outcome posts at a future CMS release |
| SURVEY 2025-10-21 · COMPLAINT (INTAKE IL-2025-08814) · CMP $105,300 + DPNA · CMS-2567 ↗ | |||
| F-689Repeat ×3 | Free of accident hazards / supervision / devices: environment free of accident hazards; adequate supervision to prevent accidents | JImmediate jeopardy · isolated | IJ removed 2025-11-03 corrected 2025-12-18 · revisit |
| F-580Repeat ×2 | Notification of changes: inform resident/representative/physician of injury, decline, or change in status | GActual harm · isolated | PoC accepted 2025-11-14 corrected 2025-12-18 · revisit |
| SURVEY 2025-03-27 · STANDARD RECERTIFICATION · CMS-2567 ↗ | |||
| F-725Repeat ×2 | Sufficient nursing staff | FWidespread · no actual harm | PoC accepted 2025-04-30 corrected 2025-05-30 · revisit |
| F-812Repeat ×2 | Food procurement, storage, preparation and service: sanitary | DIsolated · no actual harm | PoC accepted 2025-04-30 corrected 2025-05-30 · revisit |
| SURVEY 2024-09-06 · COMPLAINT (INTAKE IL-2024-06172) · CMP $67,935 · CMS-2567 ↗Within residency window | |||
| F-689Repeat ×2 | Free of accident hazards / supervision / devices | GActual harm · isolated | PoC accepted 2024-10-14 corrected 2024-11-02 · revisit |
| F-684Repeat ×2 | Quality of care: treatment and care per professional standards and the comprehensive care plan | GActual harm · isolated | PoC accepted 2024-10-14 corrected 2024-11-02 · revisit |
| SURVEY 2024-04-19 · STANDARD RECERTIFICATION · CMS-2567 ↗Within residency window | |||
| F-725 | Sufficient nursing staff | EPattern · no actual harm | PoC accepted 2024-05-27 corrected 2024-06-11 · revisit |
| F-684 | Quality of care | DIsolated · no actual harm | PoC accepted 2024-05-27 corrected 2024-06-11 · revisit |
| F-880 | Infection prevention and control: establish and maintain an infection prevention and control program | EPattern · no actual harm | PoC accepted 2024-05-27 corrected 2024-06-11 · revisit |
| SURVEY 2023-11-14 · COMPLAINT (INTAKE IL-2023-09341) · CMP $21,340 · CMS-2567 ↗ | |||
| F-689 | Free of accident hazards / supervision / devices | GActual harm · isolated | PoC accepted 2023-12-08 corrected 2024-01-09 · revisit |
| F-580 | Notification of changes | DIsolated · no actual harm | PoC accepted 2023-12-08 corrected 2024-01-09 · revisit |
| SURVEY 2023-06-08 · STANDARD RECERTIFICATION · CMS-2567 ↗ | |||
| F-812 | Food procurement, storage, preparation and service: sanitary | EPattern · no actual harm | PoC accepted 2023-07-06 corrected 2023-08-02 · revisit |
| F-761 | Label / store drugs and biologicals: in accordance with currently accepted professional principles | DIsolated · no actual harm | PoC accepted 2023-07-06 corrected 2023-08-02 · revisit |
| F-641 | Accuracy of assessments: resident assessment accurately reflects the resident's status | DIsolated · no actual harm | PoC accepted 2023-07-06 corrected 2023-08-02 · revisit |
PBJ staffing-shortfall analysis
PBJ daily nurse staffing · CY2023Q1 → CY2025Q4Payroll-based staffing, day by day, against CMS's case-mix-adjusted expectation for this facility. In 2025 Q4, reported RN hours fell below the case-mix-expected level on 58% of days, nearly double the 2023 Q1 share (31%) and well above the statewide median. F-725 (sufficient nursing staff) was cited on each of the last three standard surveys (§01).
| Quarter | 23Q1 | 23Q2 | 23Q3 | 23Q4 | 24Q1 | 24Q2 | 24Q3 | 24Q4 | 25Q1 | 25Q2 | 25Q3 | 25Q4 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Days below expected RN | 31% | 28% | 35% | 41% | 38% | 44% | 51% | 47% | 52% | 55% | 61% | 58% |
Method. A day counts as below expected when reported RN hours per resident day (PBJ Daily Nurse Staffing, payroll-based) fall below the facility's case-mix-adjusted expected RN hours (Care Compare expected-staffing values) for that day. PBJ data is self-reported payroll data subject to CMS audit; quarters post on CMS's PBJ publication lag. Full computation, inputs, and limitations: methodology v2.3 (§05, §06).
Penalty history: federal remedies
CMS Penalties dataset · 2026-06 releaseThree federal civil money penalties totaling $194,575 in the trailing 36 months, plus one denial of payment for new admissions. Amounts are as posted by CMS; state-level remedies are not included in the federal dataset.
| Imposed | Remedy | Amount | Linked survey | Status |
|---|---|---|---|---|
| 2025-11-20 | Civil money penalty (CMP) | $105,300 | Complaint survey 2025-10-21: F-689 cited at scope/severity J; F-580 at G | Final · posted by CMS |
| 2025-12-04 | Denial of payment for new admissions (DPNA) | N/A | Same survey cycle, remedy pending correction | In effect 2025-12-04 → 2026-01-17 · lifted at revisit |
| 2024-10-02 | Civil money penalty (CMP) | $67,935 | Complaint survey 2024-09-06: F-689 and F-684 cited at scope/severity G | Final · posted by CMS |
| 2023-12-19 | Civil money penalty (CMP) | $21,340 | Complaint survey 2023-11-14: F-689 cited at scope/severity G | Final · posted by CMS |
| Total federal CMPs · trailing 36 months | $194,575 | 3 CMPs + 1 DPNA · every remedy traces to a §01 survey | ||
Ownership graph: opco, propco, management, siblings
SNF All Owners + PECOS · 2026-06 releaseThe operating company, the real-estate holder, and the management company are separate entities under common control. The management company operates 12 Illinois facilities; 9 of the 12 have been cited at scope/severity G or above since 2023. CMS discloses owners with 5% or greater direct or indirect ownership or managing control.
Sources. Skilled Nursing Facility All Owners dataset (2026-06 release) cross-checked against PECOS enrollment records. CMS discloses individuals and organizations with 5% or greater direct or indirect ownership interest, or managing control. Percentages and roles above are as disclosed to CMS; sibling-facility citation counts derive from the Health Deficiencies dataset, same release.
Determination: "persistently needing correction"
ElderFacts methodology v2.3 · published 2026-04-02CRITERION 1The same F-tag is cited on two or more surveys within the trailing 36 months.
F-689: surveys 2023-11-14 · 2024-09-06 · 2025-10-21 (three surveys). F-725: surveys 2024-04-19 · 2025-03-27 · 2026-02-12 (three surveys). MET
CRITERION 2A plan of correction for that F-tag was accepted between successive citations.
F-689: PoCs accepted 2023-12-08 and 2024-10-14, each followed by a new citation of the same tag. F-725: PoCs accepted 2024-05-27 and 2025-04-30, each followed by a new citation of the same tag. MET
CRITERION 3At least one repeat citation is at scope/severity D or above.
F-689 repeats at G (2024-09-06) and J (2025-10-21). F-725 repeats at F (2025-03-27) and E (2026-02-12). MET
Citation-ready sourcing
Every number above traces to a row belowDatasets, records, and how to make them evidence
Data as of 2026-06 release · snapshot EF-WU-2026-0341CMS datasets used · release-stamped
- Health Deficiencies, nursing homes incl. rehab services2026-06 monthly release · pub. 2026-06-24
- Penalties2026-06 monthly release
- PBJ Daily Nurse StaffingCY2025Q4 file · pub. 2026-04-29
- Provider Information2026-06 monthly release
- Skilled Nursing Facility All Owners2026-06 monthly release
- PECOS enrollment recordsownership cross-check
Underlying survey records · CMS-2567
- 2567 · survey 2026-02-12 ↗standard recertification · statement of deficiencies
- 2567 · survey 2025-10-21 ↗complaint · incl. IJ documentation
- 2567 · survey 2025-03-27 ↗standard recertification
- 2567 · survey 2024-09-06 ↗complaint
- 2567 · survey 2024-04-19 ↗standard recertification
- 2567 · survey 2023-11-14 ↗complaint
- 2567 · survey 2023-06-08 ↗standard recertification
For evidentiary use · certified copies
Obtain certified copies from the state survey agency. Pages and exports from ElderFacts are working references, not self-authenticating records. Request certified copies of each CMS-2567 and survey file from the Illinois Department of Public Health (state survey agency), as records custodian; certification supports authentication under FRE 902(4) and 902(11), and the underlying reports sit within the public-records hearsay exception, FRE 803(8). Federal copies are available through the CMS regional office or FOIA.
Scope of this workup: federal survey, staffing, penalty, and ownership data for the last three inspection cycles plus complaint surveys, as published by CMS. State-only actions appear only where CMS posts them.
Standing disclosures · corrections
Disputes. When a citation is disputed on appeal, we own the number with you (IDR/IIDR): disputed citations are flagged where they appear (§01), and outcomes post at the following CMS release.
Corrections. corrections@elderfacts.com: acknowledged ≤ 1 business day; our-error fix ≤ 2; upstream-dispute annotation ≤ 5. Every correction is timestamped in the public corrections log.
Supersession. This snapshot is superseded by the live page, canonical: elderfacts.com/w/EF-WU-2026-0341 · cite the live page's release stamp.