Villa at Willow Place

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. for one (R2) of three residents reviewed. Review of the medical record reflected R2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included generalized anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/26, reflected R2 scored 6 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/16/26 at 9:53 am, R2 was observed in her room sleeping. R2 recalled an incident where someone grabbed her legs and squeezed her ankles but could not recall any further details. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a thorough abuse investigation was conducted in one (R2) of three reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 87 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 timely completion of Quarterly Minimum Data Set (MDS) assessments for four (R8, R29, R34, R82) of 25 reviewed for MDS.

Inspectors wroteBased on observation, interview and record review the facility failed to treat 2 residents (R7, R19) of 18 residents reviewed, with dignity and respect. Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/2/26, reflected R7 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included spastic quadriplegic cerebral palsy, dystonia(neuromuscular movement disorder), polydipsia(excessive, persistent thirst and consequently high fluid intake), bilateral hand contractures, and depression The MDS reflected R7 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers and eating. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to inform three residents (#4,#8,#20) of five residents reviewed of the benefits, risks, and alternatives for the prescribing of psychotropic medication. Findings Include: R8: Review of the medical record reflected R8 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and contracture of the right hand. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/7/25, reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) was not conducted due to R8 being coded as rarely/never understood. R8 was coded for upper extremity impairments on both sides (both arms) and for being dependent upon staff for activities of daily living (ADLs). [...]

Inspectors wroteBased on interview and record review the facility failed to provide completed Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) for three residents (R41, R45, R86) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for two (R1 and R64) of four reviewed for hospitalization. Findings Include:Resident #1(R1)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/21/26, reflected R1 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. The MDS reflected R1 had a BIM (assessment tool) score indicated her ability to make daily decisions was severely impaired, and she was dependent on staff for dressing, mobility, transfers, hygiene, bathing, toileting, and oral hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for three (R50, R59 and R114) of 25 reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of comprehensive significant change Minimum Data Set (MDS) assessments for one (R7) of 25 reviewed. Findings Include: Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/2/26, reflected R7 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included spastic quadriplegic cerebral palsy, dystonia(neuromuscular movement disorder), polydipsia(excessive, persistent thirst and consequently high fluid intake), bilateral hand contractures, and depression The MDS reflected R7 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers and eating. Review of R7 Electronic Medical Record on 2/11/26 at 9:22 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to formulate a Baseline Care Plan which included pertinent care needs for one (R114) of 18 reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for three residents (#4,#43,#64) of 18 reviewed. Findings Included: Resident #4 (R4) Review of the medical record demonstrated that R4 was admitted to the facility 02/26/2025 with diagnoses that included end stage renal disease, pain right and left foot, ascites (abnormal build up of fluid in the abdomen), osteoarthritis (degenerative joint disease) of left knee and bilateral hips, paranoid schizophrenia, chronic constipation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux, depression, schizoaffective disorder, dependence on dialysis, anemia (low red blood cells), insomnia (difficulty sleeping), cognitive decline, anxiety, gout (build up of uric acid in joints), hypertension, and atrial fibrillation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) follow Physician Orders for vital signs monitoring; and 2) assess and monitor respiratory status with administration of an as needed nebulizer treatment for one (R114) of 18 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent the development and/or worsening of contractures for one (R20) of three reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide palatable food for one resident (R19) of 18 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation for one (Resident #64) of 18 reviewed for accurate medical records. Resident #64(R64)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 12/11/25, reflected R64 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, urinary tract infection and spinal stenosis. The MDS reflected R64 had a BIM (assessment tool) score of 4 that indicated her ability to make daily decisions was severely impaired, and she required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting. During an observation on 2/10/2026 at 10:45 a.m., R64 was observed in bed with two staff at bedside assisting with care. R64 appeared pleasantly confused and did not appear to be oriented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oral chemotherapy medication as ordered for one (Resident #200) of three reviewed. This citation pertains to intake 2582143. Review of the clinical record revealed R200 was admitted into the facility on 4/23/25 with diagnoses that included: aphasia following cerebral infarction (impaired ability to understand or produce speech following a stroke), malignant neoplasm of upper third of esophagus (throat cancer) and vascular dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition). [...]

Inspectors wroteThis citation pertains to intakes MI00149170, MI00149191, MI00149342 and MI00150300. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to meet resident needs timely for four (Resident #2, #3, #8 and #9) of seven reviewed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant effecting 83 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 accurately complete a Minimum Data Set (MDS) assessment for one resident (#39) of 18 residents reviewed for accurate assessments. Findings Included: Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate and complete a level II screening for one (Resident #59) of one resident reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings Included: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility 10/10/2023 with diagnoses that included rheumatoid arthritis, diabetes mellitus, atrial fibrillation, post-traumatic stress disorder (PTSD), atherosclerotic heart disease (plaque buildup in artery walls), dysphagia (difficulty swallowing), bipolar disorder, paranoid schizophrenia, insomnia, right bundle branch block (disorder of electrical activity affecting heart), chronic headache, vitamin D deficiency, polyarthritis (arthritis affecting greater than five bone joints), depression, anxiety, and osteoporosis (condition making bones weak and brittle). [...]

Inspectors wroteResident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Section B-Hearing, Speech, and Vision of the MDS, with the same ARD, revealed b1000- Vision - Ability to see in adequate light (with glasses or other visual appliances) was documented as 1. Impaired. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide alternative communication devices related to vision for one Resident (#39) that was legally blind out of one resident reviewed for activities of daily living abilities. Findings Included: Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility 11/01/2023 with diagnoses that included end stage renal disease, hyperlipidemia (high fat content in blood), diabetes mellitus, congestive heart failure (CHF), legal blindness, hyperkalemia (high potassium), insomnia, dyspepsia (shortness of breath), constipation, protein-calorie malnutrition, renal dialysis, absence of right great toe, and anemia (low red blood cell count). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Range of Motion (ROM) services to prevent the possibility of decreased ROM and mobility in one resident (#59) of one resident reviewed. Findings Included: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility 10/10/2023 with diagnoses that included rheumatoid arthritis, diabetes mellitus, atrial fibrillation, post-traumatic stress disorder (PTSD), atherosclerotic heart disease (plaque build up in artery walls), dysphagia (difficulty swallowing), bipolar disorder, paranoid schizophrenia, insomnia, right bundle branch block (disorder of electrical activity affecting heart), chronic headache, vitamin D deficiency, polyarthritis (arthritis affecting greater than five bone joints), depression, anxiety, and osteoporosis (condition making bones weak and brittle). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent an elopement for one of one residents (R#74) reviewed for elopement. According to the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident # 74 (R74) was admitted to the facility on [DATE] with diagnoses of dementia, R74 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Record review reflected R74 eloped from the facility on 07/09/2024 in the afternoon and was located approximately 100 yards from the building walking down a sidewalk. Further review of that facility reported incident reflected R74 eloped from the 200 hallway door. Record review completed on the certification survey reflected R74 eloped on 11/16/24 at approximately 4:40 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable clinical practice for medication usage and administration for one resident (#54) out of 83 current facility residents. Findings Included: Resident #54 (R54) Review of the medical record revealed R54 was admitted to the facility 06/30/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), stroke, protein-calorie malnutrition, hypertension, depression, attention-deficit hyperactivity disorder (ADHD), urinary incontinence, bilateral cataracts, dementia, alcohol abuse, and chronic respiratory failure. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/08/2024 at 12:50 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper medication storage of medications for one Resident (#54) out of 83 current residents residing at the facility. Findings Included: Resident #54 (R54) Review of the medical record revealed R54 was admitted to the facility 06/30/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD), stroke, protein-calorie malnutrition, hypertension, depression, attention-deficit hyperactivity disorder (ADHD), urinary incontinence, bilateral cataracts, dementia, alcohol abuse, and chronic respiratory failure. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 12/08/2024 at 12:50 p.m. R54 was observed lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices to change oxygen tubing/nasal cannulas for one resident (#54) of three residents reviewed for oxygen usage.

Inspectors wroteThis citation pertains to MI00143905. Based on observation, interview, and record review the facility failed to provide an environment free from physical and verbal abuse for one Resident (#3) of three Residents reviewed for abuse resulting in the potential of physical and mental harm of Residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 87 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 5 (Resident #3, #14, #26, #34, #56) of 22 reviewed, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and provide appropriate personal hygiene care was completed for four (R9, R31, R72 and R14) of five residents reviewed for Activities of Daily Living, of a total sample of 22, resulting in unshaven facial hair, unkept nails, missed showers and dissatisfaction with the care provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent, daily, meaningful, individualized activities for four Residents (R9, R31, R34, R74) of four residents reviewed for care, of a total sample of 22 residents, resulting in a loss of interaction, sense of wellbeing, boredom, lack of meaning/quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sufficient staff necessary to provide care for seven out of eight anonymous resident council group from a total sample of 22, with the potential of affecting all 87 residents in the facility resulting in extended call light wait times, missed showers, and avoidable incontinence. During an observation on 01/24/24 at 08:09 AM, One CNA on 400 hall picking up breakfast trays, while two call lights were on for over 25 minutes before getting answered. During an interview on 01/24/24 at 0820 AM, anonymous CNA EE stated they used to have two CNAs on each hall before the budget cuts, now they have one to one and a half CNA's per hall. CNA EE stated hall 400 had six mechanical lift residents that require two people to transfer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate snacks for a resident with a diabetic diet for one Resident (#34) of 22 sampled, with the potential to affect 30 diabetic residents residing in the facility, reviewed for therapeutic diets, resulting in uncontrolled blood glucose levels with the potential need to have additional administered insulin and complications of hyperglycemia. Findings Include: Review of the medical record revealed R34 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included difficulty in walking, muscle weakness, type two diabetes with chronic kidney disease, hyperlipidemia, morbid obesity, and type two diabetes with neuropathy. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that eight of eight anonymous residents from the resident council meeting, with the potential of affecting all 87 residents in the facility, who were not offered a nourishing HS (nighttime) snacks on a regular basis, resulting in residents verbalizing going to bed hungry, and diabetic residents verbalizing not receiving a HS snack and the potential for low Blood Glucose levels in the morning.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively maintain the walk-in freezer refrigeration unit, (2) effectively maintain the food production kitchen flooring and wall surfaces, (3) effectively clean the mechanical dish machine ventilation hood and return-air-exhaust ventilation grill, and (4) effectively maintain the overhead spray arm valve handle rubberized deflector orifice effecting 85 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and erratic water discharge patterns.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity of one (R34) of 22 sampled residents reviewed for dignity by limiting their clothing to a hospital-style gown, resulting in an undignified appearance for a resident who is able to express clothing choices and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the hearing needs/preferences for one (Resident #17) of 22 reviewed for accommodation of needs. This deficient practice resulted in feelings of frustration, conflict for the resident residing with R17, and the potential for a suboptimal quality of life. Findings Include: Resident #17 (R17) Review of the medical record revealed R17 was admitted to the facility on [DATE] with diagnoses that included bilateral hearing loss, anemia, repeated falls, essential hypertension (high blood pressure), and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/23 revealed R17 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R17 required one person assistance for most activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident preferences related to showering for 2 (Resident #37, #65) of 2 residents reviewed for self-determination/choices, resulting in expressions of frustration and decreased fulfillment of personal autonomy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment in providing adequate personal clothing laundry services including a resolution for missing items in 1 of 22 sampled residents (Resident #28), resulting in feelings of frustration and unmet needs.

Inspectors wroteBased on observation, interview and record review, staff failed to report an injury of unknown origin timely to the Nursing Home Administrator and as a result to the State Agency for one (Resident #24) of four residents reviewed potentially resulting in the resident not being protected from abusive individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bed hold policy was provided for 1 (Resident #479) of 5 residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy.

Inspectors wroteBased on interview and record review, the facility failed to prevent weight loss in one (Resident #3) of five residents reviewed for nutritional status resulting in significant weight loss of 16.9 percent and inadequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had appropriate competencies and skill sets to provide nursing related services for one of four staff reviewed for competency, resulting in the potential for decreased quality of care and resident safety. Findings Include: Review of Nursing Home Administrator (NHA) A's employee file revealed that his date of hire was 5/28/2019. NHA A has a current Licensed Practical Nurse (LPN) license. He (NHA A) did not have an annual nursing competency completed. During an interview on 1/25/2024 at approximately 4:30 PM, Assistant Director of Nursing (ADON) C stated that NHA A didn't have a competency because he works as a NHA and not as an LPN in the facility. During an interview on 1/26/2024 at 10:06 AM, NHA A revealed that he was an LPN and helps staff out on the floor sometimes. [...]

Inspectors wroteBased on interview and record review, the facility failed to address pharmacist recommendations timely in three of five reviewed for medications (Resident #26, #31, & #37), resulting in the potential for adverse effects and decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5% when four medication errors were observed from a total of 35 opportunities for three residents (Resident #56, #71 and #281) of seven reviewed for medication administration, resulting in a medication error rate of 11.43% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and secure controlled drugs in one of four medication carts reviewed for medication storage and properly dispose of non-controlled medications, resulting in the increased likelihood for diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate effective 24-hour communication and coordination of care and services for two hospice Residents (R26 and R72) of two hospice residents reviewed, resulting in an incomplete medical record of hospice visits, plan of care, progress notes, care coordination and the potential for care needs to go unaddressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure continuing competence of nurse assistants for one of three nurse assistants reviewed for staff competency resulting in the potential for unmet resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that written notification required for facility-initiated transfers were provided to residents or resident representatives for 2 (Resident #37 and #479) of 5 residents reviewed for hospitalization, resulting in the potential of residents and/or representatives being un-informed of the reason for transfer and their appeal rights.

Inspectors wroteThis citation pertains to intake MI00141324 Based on interview and record review, the facility failed to honor an advance directive and the resident's right to refuse treatment in 1 (Resident #9) of 4 residents reviewed for Advanced Directives, resulting in CPR (Cardiopulmonary Resuscitation) being performed on a resident with a DNR (Do not Resuscitate) status.

Inspectors wroteThis citation pertains to Intake MI00141825. Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for one (Resident #8) of three reviewed, resulting in an allegation that was not reported to the State Agency and the potential for further allegations to go unreported.

Inspectors wroteThis citation pertains to intake MI00141324 Based on observation, interview, and record review, the facility failed to ensure residents received annual Level 1 PAS/ARR (Preadmission Screening/Annual Resident Review) in 1 (Resident #4) of 4 residents reviewed for PAS/ARR, resulting in the potential for unmet mental health treatment and services.

Inspectors wroteThis citation pertains to Intake MI00141825. Based on interview and record review, the facility failed to provide pressure ulcer treatments as ordered for one (Resident #8) of 4 reviewed, resulting in the potential of a worsened pressure ulcer.

Inspectors wroteThis citation pertains to Intake MI00141570. Based on observation, interview, and record review, the facility failed to maintain a system to account for the accurate usage and reconciliation of all controlled medications for one (Resident #6) of three reviewed, resulting in the potential for medication errors and drug diversion.