The Willows at East Lansing

Inspectors wroteThis citation pertains to Intake 2808417. Based on observation, interview, and record review, the facility failed to complete wound care as ordered for one (R201) of one reviewed.

Inspectors wroteThis citation pertains to Intake 2808417. Based on observation, interview, and record review, the facility failed to ensure the accuracy of medical records for one (R201) of three reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 64 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Grievance/Concern forms were readily available to residents and families to file concerns anonymously and failed to follow facility Grievance policy, resulting the likelihood of unresolved concerns and frustration. During a confidential resident group meeting on 1/07/2026 at 1:31 PM, nine of nine residents reported the facility did not offer an option to complete a grievance confidentially and reported were not aware they had access or where to locate survey results. Residents reported if anyone had a concern they had to report to staff and they would complete form electronically. Residents reported they no longer have an option to complete a paper form. During an observation on 1/7/26 at about 2:30 PM, Tour of facility with no observed grievances available for resident/family use. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Advanced Directive was completed appropriately for one (Resident #4) out of one reviewed for advanced directives.

Inspectors wroteBased on interview and record review the facility failed to confirm that the Pre-admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for 2 residents (#4 and 8) of 3 reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30-day exemption period and failed to notify the State Agency Health Authority for 1 Residents (#7) of 3 residents reviewed for PAS/ARR from a total sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for 1 resident (R# 7) of 16 reviewed.

Inspectors wroteBased on interview and record review the facility failed to routinely complete and invite residents and their representatives, if applicable, to participate in care planning for one resident (R51) of 1 reviewed for care conferences, resulting in the increased likelihood of decline in physical, mental, or psychosocial functioning. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R51 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that Multiple Sclerosis. The MDS reflected R51 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During a confidential resident group meeting on 1/07/2026 at 1:31 PM, Confident group reported that they had not been invited to routine care conferences for several months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive Care Plans for one (Resident #5) of 15 reviewed for Care Plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to update a care plan to include detailed person centered needs for one resident (#35) of 15 residents reviewed for care planning.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a meaningful, diverse and engaging activity program for one resident (#41) of one reviewed for activities.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one out of one resident (Residents #5) received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, resulting in the potential for unmet emotional and/or mental well-being care needs. Resident #5 (R5) Review of the medical record reflected R5 was admitted to the facility on [DATE] with diagnosis which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and dysthymic disorder (persistent depressive disorder). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2024, reflected R5's Brief Interview for Mental Status (BIMS) was coded as a 12, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to justify the increase in an antipsychotic medication for one (Resident #18) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to offer an updated COVID-19 immunization to two (Resident #7 and Resident #18) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer for two (Resident #19 and Resident #37) of two reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of bed hold policy for two (Resident #19 and Resident #37) of two reviewed.

Inspectors wroteThis citation pertains to MI 00145328 Based on observation, interview, and record review the facility failed to thoroughly assess or provide treatment for a hot liquid burn for one Resident (#1) out of one reviewed resulting in the potential of medical complications from a hot liquid burn. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] with diagnoses that included cerebral infarction (stroke), fracture of nasal bones, history of falls, urinary tract infection, acute respiratory failure, heart failure, hypertensive heart disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), diplopia (double vision), dysarthria (slurred speech), anarthria (inability to articulate speech), dysphagia (difficulty swallowing), osteoarthritis, gastro-esophageal reflux, and chronic pain. [...]

Inspectors wroteThis citation pertains to MI 00145328 Based observation, interview, and record review the facility failed to prevent accidents (falls) by not following the plan of care, for one Resident (#1) out of five Residents reviewed resulting in injury related to a fall. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] with diagnoses that included cerebral infarction (stroke), fracture of nasal bones, history of falls, urinary tract infection, acute respiratory failure, heart failure, hypertensive heart disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), diplopia (double vision), dysarthria (slurred speech), anarthria (inability to articulate speech), dysphagia (difficulty swallowing), osteoarthritis, gastro-esophageal reflux, and chronic pain. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure a call light was accessible for 1 out of 13 residents (Resident #11 ) reviewed, resulting in the potential for resident needs to be unmet.

Inspectors wroteBased on observation and interview, the facility failed to effectively inform 6 of 6 residents from Resident Council of their right to file a grievance, have grievance forms available to the residents and failed to provide effective information on how to file a grievance or a complaint in writing, resulting in grievances not being heard or corrected and the potential for mismanagement of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for three residents (#12,#13,#14) of 14 reviewed for MDS assessments resulting in the potential for inaccurate care plans and unmet resident needs. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to 1) complete a Level II Screening for Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification or refer to Community Mental Health for an OBRA Level II evaluation for one (Resident #13) of three reviewed for PASARR; and 2) complete a Level I Preadmission Screening/Annual Resident Review (PASARR) for one (Resident #19) of three reviewed for PASARR, resulting in the potential for lack of appropriate mental health treatment and services.

Inspectors wroteBased on interview and record review the facility failed to ensure that a Preadmission/Annual Resident Review (PAS/ARR) was accurately completed upon admission and failed to ensure an accurate PAS/ARR level one OBRA (Omnibus Budget Reconciliation Act of 1993) was sent to Community Mental Health Services Program (CMHSP) for a level two OBRA evaluation for 1 resident (Resident #48) of 3 residents reviewed for PAS/ARR, resulting in the potential for unmet mental health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Care Conferences were offered for two (Resident #19 and #30) of 13 reviewed for Care Conferences, resulting in the potential for Residents and/or their Resident Representatives not being involved in the care planning process and/or care preferences not being identified or honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful activities for two Resident (R34 and R48) of two residents reviewed for activities. This deficient practice resulted in the increased likelihood for boredom, decreased quality of life, lack of activities and basic stimulation for residents who are dependent on staff for transferring and mobility and the likelihood for depression and feelings of melancholy using the reasonable person concept for all 11 residents that reside on the memory unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement nutritional interventions to prevent further weight loss for one resident (#14) of three residents reviewed resulting in the potential for continued weight loss and decline in nutritional status. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to; 1) ensure that accurate informed consents were obtained for psychotropic medications prescribed for two residents (R34 and R256); and 2) justify the continued PRN (as needed) use and/or provide a duration of use of a psychotropic medication for one (Resident #34) of five reviewed, resulting in residents being administered antipsychotic medication without appropriate consent and risk-versus-benefit analysis of the medications explained to the resident and/or the responsible party with the increased likelihood for serious side effects and adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to date mark opened medications in two of three medication carts reviewed, resulting in the potential for residents to receive expired medications with altered potency and efficacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Voluntary Binding Arbitration Agreement was reviewed with the Resident and/or their Responsible Party for two (Resident #14 and #256) of three reviewed for arbitration, resulting in the residents and/or their representatives to not be informed of their rights.