Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Willows At East Lansing during CMS and state inspections, most recent first.
A resident with multiple sclerosis, paraplegia, MASD, an indwelling catheter, and frequent bowel incontinence had a right thigh wound with a physician order for daily wound care between 2:00 PM and 10:00 PM. During incontinence care, surveyors observed that the wound dressing was dated several days earlier, despite the TAR showing that an LPN had documented the treatment as completed on two intervening days and refused on another day. The medical record contained no documentation of wound care refusals on the dates in question, and leadership acknowledged the discrepancy, indicating the LPN may have marked the treatment as done or failed to document refusals. This demonstrated that ordered daily wound care was not consistently provided or accurately documented according to the resident’s treatment orders.
A resident with multiple sclerosis, paraplegia, bowel incontinence, and MASD to the right thigh had a physician’s order for daily wound care, yet surveyors observed a thigh dressing dated several days earlier, indicating it had not been changed as ordered. The TAR showed wound care documented as completed on multiple days and refused on one day, but the observed unchanged dressing and the absence of documented refusals on certain days conflicted with these entries. The DON acknowledged that refusals should be charted and that an LPN may have incorrectly recorded wound care as completed or failed to document refusals, resulting in an inaccurate medical record for the resident’s wound treatment.
Food service equipment and related systems were observed inadequately cleaned and maintained. A stand mixer, two ovens, and a char broiler grill had accumulated and encrusted food residue, and the air handler intake filter and exit ports were heavily soiled with dust and dirt. The mechanical dish machine final rinse temperature gauge read below the stated minimum during the final rinse cycle, and thermometer tape indicated the dish surface temperature was at least 160 degrees Fahrenheit.
A facility failed to make grievance/concern forms readily available for residents and families to use anonymously and did not follow its grievance policy. Residents reported they had to tell staff about concerns and no longer had a paper form option, while staff had difficulty locating the forms at the nurse station and the ED said paper copies were kept in a binder outside the ED office. Residents also were not aware of survey results or where to find the grievance form.
A resident with chronic atrial fibrillation and severe cognitive impairment had an Advanced Directive that was not completed correctly. The record showed the resident had a medical POA, but the signature on the declarant line did not match the appointed POA, and Social Services confirmed the signature was incorrect.
Failure to complete PASARR Level II OBRA evaluations for two residents. PASARR Level I documentation was present in both records, but no Level II OBRA evaluation could be located for either resident. Social Services staff stated both residents should have had the evaluations completed, but they were not.
PASARR screening was not completed after a resident exceeded the 30-day exemption period, and the State Agency Health Authority was not notified. The resident had bipolar disorder, anxiety, and respiratory failure, with a BIMS score of 15/15 and documentation showing use of an antidepressant or antipsychotic medication. Social workers acknowledged the resident remained in the facility beyond the exemption period without a follow-up PAS/ARR because discharge home was expected soon.
A resident admitted with acute and chronic respiratory failure, bipolar disorder, and anxiety was receiving an antipsychotic and had physician orders to monitor depression, insomnia, psychosis-related behavior, and anxiety. However, the care plan did not address mood, behavior, psychosocial well-being, or psychotropic medication use, and SWs reviewing the EMR could not locate a mental health care plan.
A resident with MS and intact cognition did not receive a required quarterly care conference, and staff confirmed the meeting was overdue. The SW, ED, and DON acknowledged that care conferences should occur quarterly with the resident and/or responsible party and care team, and residents reported they had not been invited to routine care conferences for several months.
A resident with dementia and anxiety exhibited increasing aggressive behaviors, particularly during sundowning episodes, without a comprehensive care plan in place. Despite documentation of these behaviors, the facility failed to develop interventions to guide staff. Social workers were not promptly informed of incidents, delaying care plan development for the resident's needs.
A resident with severe cognitive impairment and a history of falls had an incomplete care plan that failed to specify the placement of a floor mat, despite multiple falls from the bed. Interviews with the DON and a CNA highlighted the lack of individualized instructions, leading to uncertainty in implementing fall prevention measures.
A resident with severe cognitive impairment was not provided with a meaningful and engaging activity program. Despite having preferences for activities like pet visits and music, the resident was often observed sitting in front of a television playing MTV, which they did not engage with. The facility did not offer pet therapy and failed to document any invitations or encouragement for the resident to participate in other available activities.
A resident with dementia and anxiety exhibited increasing aggressive behaviors, including conflicts with roommates and attempts to leave the facility. Despite being on medication, there were no documented interventions to manage these behaviors, and staff were unsure of how to assist. The facility's documentation and communication were inadequate, delaying necessary follow-up by social workers.
A resident with severe cognitive impairment and a history of gradual dose reductions for Risperidone had their medication increased to twice daily after a hospital stay, without documented justification. Facility staff, including social workers and the DON, could not provide a rationale for the change, and behavior reports did not indicate significant disturbances. The resident's daughter reported increased hallucinations, but no new orders were made.
The facility failed to offer an updated COVID-19 immunization to two residents who had previously contracted COVID-19. Both residents, with cognitive impairments and guardians, received their last COVID-19 vaccine in 2022. Despite being eligible for a booster 90 days post-infection in 2023, there was no documentation that they were offered the vaccine, resulting in a deficiency.
The facility failed to provide written transfer notices for two residents during hospital transfers. One resident, cognitively intact, was transferred three times without notice, while another with moderate cognitive impairment was transferred without notice during a hospitalization for urosepsis. Staff interviews confirmed the absence of required documentation.
The facility failed to provide two residents with written notice of the bed hold policy during hospital transfers. One resident, who was cognitively intact, was transferred multiple times without receiving the notice, as confirmed by staff interviews. Another resident with moderate cognitive impairment also did not receive the notice during a hospitalization, with staff indicating process changes may have contributed to the oversight.
A resident with a history of multiple medical conditions spilled mild temperature beverages on her lap, resulting in burns that were not properly assessed or treated by the facility. Initial assessments noted mild redness, but later observations revealed open areas on the thighs. Despite reports of blisters and redness by staff, no treatment orders or documentation were found in the resident's medical records.
A resident with a history of falls was left unattended in the shower by a CNA, resulting in a fall and injury. The resident, who did not request privacy, fell while reaching for a washcloth, leading to a hospital visit for stitches. The CNA assumed privacy was desired, despite knowing the resident's fall risk, and was later re-educated on proper supervision protocols.
Failure to Provide and Accurately Document Ordered Daily Wound Care
Penalty
Summary
Surveyors identified that ordered wound care was not completed as prescribed for a resident with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD). The resident’s MDS showed moderate cognitive impairment. A physician’s order dated 3/15/26 directed that the right thigh wound be cleansed with normal saline or wound cleanser, patted dry, skin prep applied to the peri-wound, collagen applied to the wound bed, and a border dressing applied, with the treatment to be done daily between 2:00 PM and 10:00 PM. A wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care for loose stool that had leaked from the brief and soiled the bedding, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date. Review of the Treatment Administration Record (TAR) showed that the daily wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The medical record contained no indication that the resident refused wound care on 3/16/26 or 3/19/26. The DON acknowledged that the TAR reflected wound care as completed on 3/17/26 and 3/19/26 and stated that the LPN might have clicked it off as completed or forgotten to document refusals, while attempts by both surveyors and facility leadership to contact the LPN for clarification were unsuccessful. The ADON, who served as the wound nurse, confirmed that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. These observations and record reviews showed a failure to provide and accurately document the ordered daily wound care for the right thigh wound.
Inaccurate Wound Care Documentation for Thigh MASD
Penalty
Summary
The deficiency involves the facility’s failure to ensure the accuracy of a resident’s medical record regarding wound care. The resident, admitted with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD), had a physician’s order dated 3/15/26 for daily wound care to a right thigh wound between 2:00 PM and 10:00 PM. The wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care following an episode of loose stool incontinence that required a complete linen change, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date. A CNA confirmed the dressing date of 3/16/26. Review of the Treatment Administration Record (TAR) showed that the resident’s wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The facility was unable to reach the LPN to clarify the documentation. The ADON, who served as the wound nurse, stated that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. The DON stated that any wound care refusals should be documented in the Progress Notes or TAR and acknowledged that the TAR showed wound care as completed on 3/17/26 and 3/19/26, suggesting the LPN might have incorrectly documented completion or failed to document refusals. The resident’s medical record did not indicate that wound care was refused on 3/16/26 or 3/19/26, resulting in inaccurate medical record documentation related to wound treatment.
Food Service Equipment and Dish Machine Not Properly Maintained
Penalty
Summary
Food service equipment and related systems were found to be inadequately cleaned and maintained during survey observations and record review. On 01/06/2026, the Globe stand mixer was observed soiled with accumulated and encrusted food residue. Two South Bend ovens were also observed with soiled interior and exterior surfaces, and the South Bend char broiler grill plate, backsplash, side panels, and front splash were heavily soiled with accumulated and encrusted food residue. The Director of Food Service stated the soiled equipment would be cleaned as soon as possible. The air handler intake filter and exit ports were also observed heavily soiled with accumulated and encrusted dust and dirt deposits, and the Director of Food Service stated the concern would be placed into TELS. Later that day, the mechanical dish machine final rinse temperature gauge was observed reading 168-170 degrees Fahrenheit at the manifold during the final rinse cycle, below the stated minimum of 180 degrees Fahrenheit. Thermometer tape was used to check the final rinse temperature at the dish surface and turned black, indicating at least 160 degrees Fahrenheit. The Director of Food Services stated the temperature gauge replacement would be entered into TELS. Record review showed the air handler filters were changed quarterly, and the last filter replacement was completed on 12/8/2025. Policy review showed cleaning procedures for the grill and mixer, including disassembly, washing, rinsing, sanitizing, and air drying.
Grievance Forms Not Readily Available to Residents and Families
Penalty
Summary
The facility failed to ensure grievance and concern forms were readily available to residents and families for anonymous use, and it did not follow its grievance policy as written. During a confidential resident group meeting, nine of nine residents reported the facility did not offer an option to complete a grievance confidentially and that they were not aware they had access to survey results or where to locate them. Residents stated that if they had a concern, they had to report it to staff, who would complete the form electronically, and they reported there was no longer an option to complete a paper form. During observation, no grievance forms were seen available for resident or family use. RN C reported residents and families verbally report concerns to staff, who report them to the DON, and she spent over 10 minutes looking for paper concern forms at the nurse station before the DON located them in a file cabinet behind the nurse station. SW H and I also reported the forms should be available at the nurse station without asking, but they were unable to locate them. The ED stated paper copies were available in a binder labeled survey results outside the ED office and that the compliance poster with the corporate complaint number and QR code was posted in a common area, but residents in the group meeting were not aware of the survey results or concern form location. The facility policy stated grievances or concerns can be filed verbally, in writing, or anonymously, and that the resident or representative has the right to receive a copy of the written grievance.
Incorrect Signature on Advanced Directive
Penalty
Summary
The facility failed to ensure the Advanced Directive was completed appropriately for one resident. The resident was admitted with diagnoses including chronic atrial fibrillation and had severe cognitive impairment, with an MDS BIMS score of 4 out of 15. The medical record showed the resident had a medical power of attorney, but review of the Advanced Directive found that the signature on the declarant signature line did not match the name of the appointed medical power of attorney. During interview, Social Services H verified that the signature on the Advanced Directive was incorrect and should have been signed by the medical power of attorney.
Failure to Complete PASARR Level II OBRA Evaluations
Penalty
Summary
The facility failed to confirm that PASARR Level I determination requests were sent to the Community Mental Health Service Program for Level II OBRA evaluations for 2 of 3 residents reviewed. Resident 4 was admitted with chronic atrial fibrillation, and Resident 8 was admitted with type 2 diabetes mellitus. During record review, PASARR Level I documentation was found in both residents’ medical records, but no Level II OBRA evaluation could be located for either resident. In an interview, Social Services staff member H stated that both residents should have had Level II OBRA evaluations completed, but neither evaluation was completed.
PASARR Not Completed After 30-Day Exemption
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed after the 30-day exemption period for Resident #7, and the State Agency Health Authority was not notified. The resident was admitted with diagnoses including acute and chronic respiratory failure, bipolar disorder, and anxiety. The MDS dated 12/09 showed a BIMS score of 15 out of 15. The 3877 portion of the PAS/ARR dated 12/4/25 documented bipolar disorder and routine use of an antidepressant or antipsychotic medication within the last 14 days, and the 3878 portion dated 12/05/25 showed the resident was admitted with a 30-day exemption. There was no further PAS/ARR completed after the resident remained in the facility beyond the exemption period. During interview, Social Workers H and I acknowledged the resident was still at the facility beyond 30 days without a follow-up PAS/ARR, and Social Worker H stated the resident was expected to discharge home soon and that a new 3877 was not completed and Community Mental Health was not notified because of that expectation.
Failure to Develop Mental Health and Psychotropic Care Plans
Penalty
Summary
The facility failed to develop and implement care plans for Resident #7, who was admitted with acute and chronic respiratory failure, bipolar disorder, and anxiety. The resident’s MDS dated 12/09 showed a BIMS score of 15 out of 15. Physician orders showed the resident was admitted on an antipsychotic medication and, on 12/08/25, had four separate orders to monitor and track mood and behavior related to depression, insomnia, behavior related to psychosis, and anxiety. Despite these diagnoses, medication use, and behavior-monitoring orders, the resident’s care plans did not include any plans to address mood, behavior, psychosocial well-being, or psychotropic medication use. During an interview on 01/07/2026, Social Workers H and I reviewed the EMR and were unable to locate a care plan addressing the resident’s mental health concerns, and Social Worker H stated that care plans for mood, behavior, and psychosocial well-being should have been developed and implemented.
Missed Quarterly Care Conference
Penalty
Summary
The facility failed to routinely complete care conferences and failed to invite residents and their representatives, if applicable, to participate in care planning for one resident. R51 was a female resident admitted with a diagnosis of Multiple Sclerosis. Her MDS reflected a BIM score of 15, indicating she was cognitively intact and able to make daily decisions. Review of records and interviews showed that her last care conference was in August 2025 and that she should have had a quarterly care conference in November 2025, but it was missed. During a confidential resident group meeting, residents reported they had not been invited to routine care conferences for several months. The Social Worker stated care conferences should occur quarterly with the resident and/or responsible party and members of the care team, and acknowledged that R51’s conference was late. The Executive Director and DON also stated care conferences were expected at least quarterly and verified that R51 did not receive the required care conference in November 2025, with the Executive Director confirming the resident was currently out of compliance.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, resulting in the potential for unmet care needs. The resident, who was admitted with diagnoses including unspecified dementia and anxiety, exhibited moderate cognitive impairment. Despite being on an antidepressant, the resident displayed increasing aggressive behaviors, particularly during sundowning episodes. These behaviors were documented in progress notes, but no care plan was developed to address the resident's increased confusion and aggression at night. Observations and interviews revealed that the resident expressed frustration with personal property issues and had conflicts with roommates, leading to aggressive incidents. Staff noted the resident's sundowning behaviors were becoming more frequent and aggressive, yet there were no interventions listed to guide staff on managing these behaviors. The interdisciplinary team was aware of the behavior concerns but had not developed a care plan to address them. The social workers involved were not immediately informed of a significant incident involving the resident and a roommate, delaying the development of a care plan. The lack of timely communication and follow-up resulted in the absence of a care plan for the resident's behaviors, including increased nighttime delirium and depression. This oversight highlights the facility's failure to ensure comprehensive care planning for the resident's needs.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update a care plan to include detailed person-centered needs for a resident with severe cognitive impairment and a history of falls. The resident was admitted to the facility and had multiple falls since admission, resulting in abrasions to the forehead and left knee. Observations noted that the resident had a floor mat in their room, but the care plan did not specify which side of the bed the mat should be placed on, despite the resident's history of falling from the bed. Interviews with the Director of Nursing and a Certified Nursing Assistant revealed that the care plan was not individualized to specify the placement of the floor mat, which is crucial for preventing falls. The CNA indicated that care is driven by the care plan, and without specific instructions, staff would have to guess or rely on verbal reports to determine the correct placement of the mat. This lack of specificity in the care plan contributed to the deficiency in providing adequate fall prevention measures for the resident.
Failure to Provide Engaging Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident diagnosed with a neurocognitive disorder with Lewy body, who was admitted with severe cognitive impairment. The resident's activity assessment indicated preferences for pet visits, being read to, easy listening music, and family visits. However, the facility's activity care plan included activities such as pet therapy, which was not offered, and other activities like Catholic services, going outside, bingo, socials, and music, which were not documented as attended by the resident. Observations over several days showed the resident repeatedly placed in front of a television playing MTV, which the resident did not engage with. Despite the facility having books, music programs, and socials, there was no documentation of the resident being invited or encouraged to participate in these activities. The Nursing Home Administrator acknowledged the lack of pet therapy and did not provide an explanation for the resident's lack of participation in other activities, nor was there any record of the resident refusing invitations to group activities.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #5 (R5), who was admitted with diagnoses including unspecified dementia, anxiety, and dysthymic disorder. R5 exhibited moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 12. Despite being on an antidepressant, Escitalopram, R5 displayed increasing aggressive behaviors and agitation, particularly during the evening, known as sundowning. These behaviors included attempting to leave the facility, conflicts with roommates, and difficulty being redirected by staff. Observations and interviews revealed that R5's aggressive behaviors were not effectively managed, as there were no documented interventions to guide staff in addressing these behaviors. Incidents included R5 becoming agitated with a roommate over a closed door, throwing a roommate's shoes in the trash, and needing a room change due to conflicts. Staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), noted the increase in frequency and intensity of R5's behaviors but were unsure of any specific interventions in place. The facility's documentation and communication processes were inadequate, as evidenced by the lack of progress notes or social work assessments regarding R5's recent incidents. Social Workers were not informed of a significant incident until days later, delaying necessary follow-up. The absence of a comprehensive care plan with individualized interventions for R5's behavioral issues contributed to the deficiency in providing appropriate behavioral health care and services.
Unjustified Increase in Antipsychotic Medication for a Resident
Penalty
Summary
The facility failed to justify the increase in antipsychotic medication for a resident, identified as Resident #18, who was admitted with diagnoses including anxiety, major depressive disorder, and vascular dementia with psychotic disturbance. The resident had a history of gradual dose reductions (GDR) for Risperidone, an antipsychotic medication, with the last reduction noted on 12/19/23. Despite this, the resident's medication was increased to twice daily following a hospital stay from 3/21/24 to 4/3/24, without documented rationale for the change. The facility's records indicated that the resident was receiving Risperidone once daily, but observations and interviews revealed that the medication was administered twice daily. The facility's social workers and the Director of Nursing were unable to provide documentation or rationale for the increased dosage of Risperidone. The behavior analysis report and progress notes did not indicate any significant behavioral disturbances or distressful hallucinations that would justify the increase. The resident's daughter expressed concerns about increased hallucinations, but no new orders were made following this report. The lack of documentation and justification for the medication increase was noted as a deficiency by the surveyors.
Failure to Offer COVID-19 Booster to Residents
Penalty
Summary
The facility failed to offer an updated COVID-19 immunization to two residents, identified as Resident #7 and Resident #18, who were reviewed during a survey. Resident #7 was admitted with diagnoses including diabetes, sleep apnea, and vascular dementia, and had a moderate cognitive impairment score on the Brief Interview for Mental Status (BIMS). Resident #18 was admitted with atrial fibrillation, heart failure, and dementia, and had a severe cognitive impairment score on the BIMS. Both residents had guardians and received their last COVID-19 immunization on November 11, 2022. There was no documentation indicating that they were offered the COVID-19 booster for 2023/2024. During interviews, the Infection Preventionist (IP) confirmed that both residents had a COVID infection in November 2023, which initially made them ineligible for the booster at that time. However, the facility's physician indicated that the residents would have been eligible to receive the COVID-19 immunization 90 days after testing positive. Despite this, there was no documentation that the residents were offered the immunization in 2023/2024, leading to the deficiency noted in the report.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer for two residents, Resident #19 and Resident #37, as required. Resident #19, who was cognitively intact and their own decision-maker, was transferred to the hospital on three occasions without receiving a written notice of transfer. Interviews with facility staff, including a social worker, registered nurse, and assistant director of nursing, confirmed that the only paperwork provided during these transfers included a Continuity of Care Document, face sheet, and a petition to psychiatric services, but not a written transfer notice. Despite an email from the Nursing Home Administrator indicating that transfer notices could be found in the electronic medical record system, no such documentation was located. Similarly, Resident #37, who had moderate cognitive impairment and was their own decision-maker, was transferred to the hospital without receiving a written notice of transfer. The resident had been readmitted after a hospitalization for urosepsis, and no written notice was found for the June hospitalization. Interviews with the Director of Nursing and Clinical Support Nurse revealed that process changes were occurring around that time, which may have contributed to the oversight. Despite requests for documentation, no further documents were submitted before the survey exit.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to two residents upon their transfer to the hospital. Resident #19, who was cognitively intact and their own decision-maker, was transferred to the hospital multiple times without receiving the required written notice. Interviews with the social worker, registered nurse, and assistant director of nursing confirmed that the only paperwork provided during these transfers included a Continuity of Care Document, face sheet, and other specific documents, but not the bed hold policy. The nursing home administrator indicated that residents are provided the bed hold policy upon admission, but there was no documentation to support that Resident #19 received this notice during any of their hospital transfers. Similarly, Resident #37, who had moderate cognitive impairment and was their own decision-maker, was readmitted to the facility after hospitalizations without receiving a written notice of the bed hold policy. Although a notice for a previous hospitalization was submitted, there was no documentation for the June hospitalization. Interviews with the clinical support nurse and director of nursing revealed that process changes were occurring around that time, which may have contributed to the oversight. No further documentation was provided before the survey exit, indicating a lapse in the facility's procedure for notifying residents of the bed hold policy during hospital transfers.
Failure to Provide Treatment for Resident's Burn
Penalty
Summary
The facility failed to thoroughly assess or provide treatment for a hot liquid burn for a resident, resulting in the potential for medical complications. The resident, who had a history of cerebral infarction, heart failure, and other medical conditions, spilled mild temperature beverages on her lap during dinner. Initial assessments noted mild redness with no blistering, and the resident requested Tylenol for mild discomfort. However, subsequent observations revealed open areas on the resident's thighs, which were not attributed to the spill by the Director of Nursing (DON), who claimed they were due to scratching. The DON could not provide documentation of required skin assessments or any treatment orders for the burn or open areas. Interviews with staff and the resident indicated that blisters had developed after the spill, and no treatments were applied to the affected areas. A Certified Nursing Aide (CNA) reported observing blisters and redness and communicated this to nursing management and the Nursing Home Administrator. Despite these observations, the resident's medical records did not show any treatment or medication orders for the burn, nor were there any photographs of the affected areas. This lack of documentation and follow-up care highlights the facility's failure to provide appropriate treatment and care according to orders and the resident's needs.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent accidents by not adhering to the care plan for a resident with a history of falls. The resident, who had multiple medical conditions including a history of falls, was left unattended in the shower by a certified nursing aide. The resident fell off the shower chair while reaching for a washcloth, resulting in a laceration on the forehead that required hospital treatment and stitches. The resident stated that she had not requested privacy during the shower, contradicting the aide's assumption that privacy was desired. The Director of Nursing and a registered nurse confirmed that the resident was left alone in the shower, despite being a known fall risk. The certified nursing aide admitted to leaving the resident unattended based on an assumption of privacy, acknowledging awareness of the resident's fall risk. The aide received re-education following the incident, emphasizing that residents with a history of falls should not be left alone during shower care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of East Lansing | 2.4 mi | ★★★★★ | 28 | 0 |
| Burcham Hills Retirement Center | 3.5 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Campus Area | 4 mi | ★★★★★ | 11 | 0 |
| Medilodge Of Capital Area | 5.3 mi | ★★★★★ | 5 | 0 |
| Medilodge Of Okemos | 5.4 mi | ★★★★★ | 13 | 0 |
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