Cycle 1
Health 2024-08-22 · Fire 2024-08-22
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rockford, IL
Willows Health Center
4-star overall rating with 4-star inspections with $12,909 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
4054 Albright Lane, Rockford, IL
(815) 316-1500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
31
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
355
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.15
Composite VBP score used to determine payment impact.
Payment multiplier
1.0234
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.26
Baseline 21.41% · Performance 18.07% · Measure score 7.26 · Achievement 7.26 · Improvement 7.13
Healthcare-associated infections
6.96
Baseline 5.66% · Performance 5.76% · Measure score 6.96 · Achievement 6.96 · Improvement 0
Total nurse turnover
7.42
Performance 33.33% · Measure score 7.42 · Achievement 7.42 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.32% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 2.61% · Lower 95% interval 5.54% |
| Discharge to community | 72.66% |
50.57%
22.1 pts better
|
Better than the National Rate · Eligible stays 106 · Observed rate 70.75% · Lower 95% interval 59.98% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.93% |
95.27%
2.3 pts worse
|
Numerator 92 · Denominator 99 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 99 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 42 · Denominator 80 |
| Discharge mobility score | 58.75% |
50.94%
7.8 pts better
|
Numerator 47 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 99 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 5.76% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 1.37% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.5% |
56.45%
1 pts better
|
Numerator 46 · Denominator 80 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 7 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
89.6%
1.7 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 87.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.4% |
18.5%
22.9 pts worse
|
19.6%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.4% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
15.0%
7.3 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.1%
1.4 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
21.3%
4.7 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.2%
3.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.6% |
68.8%
15.8 pts better
|
81.7%
2.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.2% · Q2 84.5% · Q3 82.5% · Q4 87.1% · 4Q avg 84.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
14.0%
2.1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 13.8% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.3%
2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.4% |
63.0%
28.6 pts worse
|
79.7%
45.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
26.2%
0.5 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 21.6% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-09-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-09-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-26
F · Potential for more than minimal harm
2023-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-26
F · Potential for more than minimal harm
2022-07-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-07-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-07-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-07-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-26
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-11-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-01-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-10
D · Potential for more than minimal harm
2024-09-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-08-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-13
D · Potential for more than minimal harm
2023-09-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-04
G · Actual harm
2022-07-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-17
F · Potential for more than minimal harm
2022-07-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-17
F · Potential for more than minimal harm
2022-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-17
Penalties and ownership
What sits behind the stars
$0
2025-11-15
Payment Denial
Payment Denial · denial start 2025-12-18 · 15 days
15 day denial
$12,909
2023-12-11
Fine
Fine · fine $12,909
Fine
Ownership
Dittmer, Helen
Corporate Director · Individual
Dittmer, Helen
Corporate Officer · Individual
Nelson, Brett
Corporate Officer · Individual
Salinas, Frances
Corporate Officer · Individual
Salinas, Frances
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
River Bluff Nursing Home
Rockford, IL
3-star overall rating with 4-star inspections with $10,199 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Rock River Health Care
Rockford, IL
2-star overall rating with 2-star inspections with abuse icon flag with $72,260 in total fines with 20 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#3
East Bank Center, LLC
Loves Park, IL
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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