The Willows at Okemos

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 67 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive assessment timely for three Residents (#12, #58, #68) of seventeen residents reviewed for comprehensive assessments. Findings Included: R12: Review of the medical record reflected R12 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and chronic obstructive pulmonary disease (COPD). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/26, reflected R12 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/15/2026 at 4:39 PM, R12 was observed seated in his wheelchair, in the dining room. As of 4/16/26, the status of R12's Annual MDS, with an ARD of 3/4/26, was Finalized. Section V (Care Area Assessment (CAA) Summary) of the MDS was signed on 4/16/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly assessment for three Residents (#49, #51, #61) of seventeen residents reviewed for comprehensive assessments. Findings Included:Resident #49 (R49) Review of the medical record revealed that R49 was admitted to the facility 05/08/2019 with diagnoses that included heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, hyperlipidemia (high fat content in blood), epilepsy (neurological disorder with seizures), chronic pain, osteoarthritis (degenerative joint disease), osteoporosis (bone weaking), obesity, and chronic obstructive pulmonary disease (COPD). Review of R49's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed that R49 had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (R12) of 17 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Care Plan for one (R9) of 17 reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pharmacy recommendations for one resident (#36) of five residents reviewed for pharmacy services. Findings Included:Resident #36 (R36)Review of the medical record revealed that R36 was admitted to the facility 11/04/2021 with diagnoses that included right ulna fracture, dysphagia (difficulty swallowing), depression, insomnia, anxiety, stroke, type 2 diabetes, hypertension, and pain. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/2026 revealed that R36 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. On 04/14/2026 at 08:57 a.m. during observation R39 was observed lying in bed. R39 was pleasant during interview and expressed no concerns. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a timely dental services referral for one (R54) of two reviewed.

Inspectors wroteThis Citation Pertains to Intake Number MI00152440. Based on interview and record review, the facility failed to ensure adequate supervision, implementation of meaningful and resident-centered care plan interventions, and staff awareness of planned interventions for fall prevention for two residents (Resident #701 and Resident #704) of three residents reviewed, resulting in Residents with a known risk of falls experiencing falls with injury, including a fracture, necessitating emergency medical treatment and unnecessary pain and discomfort.

Inspectors wroteThis Citation Pertains to Intake Number MI00152440. Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) and hygiene care were provided to one resident (Resident #704) of three residents reviewed.

Inspectors wroteResident #34 (R34) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/24, reflected R34 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), malnutrition and depression. The MDS reflected R34 had a BIM (assessment tool) score of 10 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 11:45 AM, R34 was in room sitting in wheelchair with some difficulty answering questions. R34 family was present and reported was currently receiving hospice services. Review of R34's Physician Orders, dated 9/26/24, reflected an order for Hospice services. Review of R34's Significant Change MDS, dated [DATE], reflected no evidence that resident 34 was on Hospice services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate storage of medications, including narcotics in 2 of 5 medication carts, resulting in the potential for misuse, and medication administration errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for one dependent resident (R4) reviewed of ADL care, resulting in increased likelihood of feelings of worthlessness, disrespect and the potential for uncleanliness. Resident #4(R4) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 , reflected R4 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), venous insufficiency (decreased blood flow in legs), cirrhosis of the liver (decreased liver function), pressure ulcer stage III, and depression. [...]

Inspectors wroteThis citation pertains in intake MI00148900. Based on observation, interview, and record review, the facility failed to ensure care and services was provided for two of 17 residents (R3 and R4) reveiwed resulting in a delay in treatment to maintain the highest practical level of wellbeing and care needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely ophthalmology services for one (Resident #49) of one reviewed for vision, resulting in lack of timely eye care services and the missed treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurate medical records for two (R7, R49) of 17 residents reviewed for medical records.

Inspectors wroteThis citation pertains to intake number MI00146626. Based on observation, interview and record review the facility failed to ensure one out of three residents (Resident #1) Physician's orders and treatment were correct and documented. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of R1's Hospice records revealed R1 was admitted to Hospice on 8/8/2024. Review of Physician's orders dated 8/14/2024, revealed R1 was made a no code (DNR). Review of R1's medication administration record (MAR) for the month of August 2024 revealed R1 was to have her blood sugar level checked before each meal and at bedtime. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 59 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for one (Resident #22) of 15 reviewed for care plans, resulting in the potential for unmet care needs. Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), pulmonary fibrosis (damaged and scarred lung tissue), pneumonia and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/23, reflected R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for oxygen use and frequent bowel and bladder incontinence. The MDS completion date was 12/26/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely assessment and follow-up for a change in condition for one (Resident #22) of 15 reviewed, resulting in the potential for delayed identification of changes in condition and delay in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 59 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included: During observation on 01/04/2024 at 03:21 p.m. the facility document entitled Todays Staffing was observed to be posted outside of the Director of Nursing Office, which was located at the beginning of the 200 hall. The Todays Staffing, dated 01/04/2024, listed the scheduled hours for all nursing staff but did not list any actual hours worked. The facility did not have actual hours worked for the previous date of 01/03/2024. In an interview on 01/04/2024 at 03:36 p.m. Nursing Schedular E explained that she post the scheduled nursing hours daily. [...]

Inspectors wroteThis citation pertains to intake MI00139030. Based on interview and record review, the facility failed to ensure laboratory tests were performed timely for two (Resident #2 and #4) of five reviewed for laboratory services, resulting in the potential for delayed treatment and lack of care coordination.