Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Villa At Willow Place during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and anxiety reported to a visitor that a CNA held her down and pushed on her during night-shift care, leading staff to notify an LPN and the NHA late in the morning. The NHA began the investigation and delayed reporting the allegation to the State Agency until later that night, despite the facility’s abuse policy requiring that such allegations be reported immediately and no later than 2 hours after they are made. The facility’s policy and federal guidance also require examining and interviewing the resident and other potentially affected residents, but there was no evidence that other residents assigned to the CNA were assessed or interviewed to determine if they had experienced abuse.
A resident with anxiety and severe cognitive impairment reported to a visitor that a CNA held her down, pushed on her during care, and later recalled someone grabbing her legs and squeezing her ankles. Nursing documentation and an incident report reflected that staff were alerted late in the morning, and the NHA/abuse coordinator began an investigation and reported the allegation to the state later that day. The CNA confirmed she was on duty and was the staff member named in the allegation. However, despite policy and regulatory requirements to promptly report abuse allegations and to examine, assess, and interview the resident and other potentially affected residents, the facility’s investigation lacked evidence that any other residents assigned to the CNA were interviewed or assessed for possible physical abuse.
Walk-in freezer equipment was not effectively maintained, with surveyors observing ice dams, frozen condensation on the ceiling, and ice buildup on frozen food containers and boxes stored in the unit. The FSD and MD reported the freezer had a long history of ice buildup and recurring issues, with monthly ice removal and prior repairs, but the problem continued.
Late Quarterly MDS Assessments: The facility failed to complete Quarterly MDS assessments on time for four residents. One resident with Alzheimer’s disease and contractures had a Quarterly MDS still in progress, while another resident with dysarthria after CVA had a Quarterly MDS completed late. The MDS Coordinator reported being about one month behind on assessments and confirmed two additional Quarterly MDSs were completed after the required 14-day timeframe.
Failure to Maintain Resident Dignity and Respect: Two cognitively intact residents were not treated with dignity and respect. One resident with cerebral palsy and contractures repeatedly had his soft touch call light left out of reach on the floor between the bed and wall, including while staff were in the room assisting with meals, and he reported some staff were not patient when listening to his needs. Another resident with stroke-related deficits reported the facility ran out of his medium briefs and he had to wear ill-fitting extra-large briefs; a CNA confirmed the facility had run out of resident supplies such as briefs and wipes.
Missing Informed Consent for Psychotropic Medications: The facility failed to document informed consent for psychotropic meds for three residents. Records showed orders for antipsychotic, antidepressant, and anti-anxiety meds, but no consents were found for Seroquel, Lorazepam, Mirtazapine, Aripiprazole, Olanzapine, Sertraline, or Trazodone. One resident with Alzheimer’s disease was dependent for ADLs, another had Huntington’s disease, dementia, and depression, and a third was cognitively intact with multiple psychiatric and medical diagnoses.
Incomplete SNF-ABN Forms for Three Residents: The facility failed to complete SNF-ABN forms for three residents by leaving the estimated daily/item cost blank on forms that listed PT, skilled nursing, OT, and room and board. The BOM stated the form should include the resident name, date, last covered date, and a daily rate, and that this information is important for the resident's decision about continuing services.
Failure to Notify Representatives of Bed-Hold Policy and Transfer Reason: The facility failed to provide written notice of the bed-hold policy and the reason for hospital transfer for two residents. Both residents had severe cognitive impairment and required extensive staff assistance with ADLs. EMRs showed hospital transfers, but there was no evidence that their responsible parties received the required written notification, and the DON could not provide proof that the notices were given.
Delayed Completion of MDS Assessments: The facility failed to complete required admission and annual MDS assessments on time for three residents. One resident admitted with ocular laceration, DM, CHF, and COPD had an admission MDS still in progress beyond the required completion window, and two other residents had annual comprehensive MDS assessments that remained incomplete past their due dates. The MDS Coordinator reported being about a month behind and stated several assessments were incomplete.
A resident with spastic quadriplegic cerebral palsy, dystonia, polydipsia, bilateral hand contractures, and depression had a significant change MDS that remained incomplete. The MDS Coordinator stated the assessment should have been completed within 14 days and was late, and also reported there were several other late MDS assessments.
Baseline Care Plan Missing Pertinent ADL Needs: A resident admitted with ocular laceration, DM, CHF, and COPD did not have a Baseline Care Plan with pertinent care needs within 48 hours of admission. The admission MDS was still in progress, and the resident’s care plan interventions for ADLs such as bathing, bed mobility, toileting, transfers, and eating were not added until later. The DON stated nurses completed initial care planning and that ADL care plans were expected to include key assistance levels.
A facility failed to complete comprehensive care plans for residents with ESRD on dialysis, ADL self-care deficits, and a Foley catheter. One resident’s dialysis care plan had a blank intervention section despite a T/TH/Sat dialysis order, another resident’s ADL plan lacked key assistance details such as bathing, toileting, transfers, and eating, and a third resident’s Foley catheter care was not added to the care plan in a timely manner.
Failure to monitor vital signs and assess respiratory status for a resident with COPD and CHF. The MAR showed an order for vital signs twice daily and PRN, but the record did not consistently document temperature, pulse, respiratory rate, or O2 saturation, and an as-needed albuterol nebulizer was given without a documented respiratory assessment before or after treatment. The resident reported shortness of breath and said a requested breathing treatment was not provided.
Failure to Provide Ordered ROM for a Resident With Contractures: A resident with Huntington's Disease, dementia, and depression was observed with both knees held in a flexed position while seated and in bed. The record included orders and a CNA care guide for active and passive ROM with ADL care, but there was no documentation that ROM had been provided in the prior 30 days. An LPN said the resident was on a contracture list and ROM was to begin later, while a CNA reported the lower-extremity contractures had worsened and that only stretching during care was being done instead of a ROM program.
Failure to provide palatable and appealing meals: A resident with CVA, polyneuropathy, anxiety, and L-sided hemiplegia/hemiparesis reported repeated meal issues, including cold food, overcooked vegetables, limited variety, lack of flavor, and missing condiments. During meal observations, the resident was served a corn dog, squash, cold pasta, and later a cheeseburger with cheese only and coleslaw, and stated food was sometimes late on weekends and that some items caused diarrhea. The grievance log also included complaints about cold food and paper plates with no desserts.
Improper garbage disposal was observed when surveyors found multiple dumpsters outside the facility, including a new trash dumpster with full bags of trash and other items on the ground around it. The FSD reported the facility had recently changed ownership and the prior garbage company had not yet removed the dumpsters, while the MD stated the facility had communicated with the prior company but the two full dumpsters remained in place. Review of records showed no follow-up communications for the dumpster removal during the noted period.
Inaccurate Documentation of Wound Care: An LPN documented a wound treatment as completed even though she later stated she did not perform it because she could not locate the wound. The resident had dementia and a coccyx pressure wound, and the MAR, progress notes, and wound consult documentation were inconsistent, with the wound nurse confirming the wound was still present and the DON stating the charting would be falsification of medical records.
A resident with esophageal cancer and cognitive impairment did not receive prescribed oral chemotherapy (capecitabine) for about 30 days due to a lapse in active orders and lack of documentation supporting discontinuation. Facility staff interviews revealed that medication changes after outside appointments were not properly reviewed, and the gap in administration was linked to the termination of the NP who had written the previous order.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. A resident reported being left soiled due to long call light response times, while another experienced over 15-minute delays at night. Two residents with moderate cognitive impairment faced extended waits for incontinence care and assistance with transfers. CNAs were assigned 14-15 residents each, limiting their ability to provide timely care. The DON was unaware of these issues, and the facility could not track call light response times.
The facility failed to maintain and clean food service equipment, affecting 83 residents and increasing the risk of cross-contamination. Observations included a weak freezer door closer, worn cooler gasket, soiled fry pans, and insect carcasses in light covers. Equipment like ovens and mixers were heavily soiled, and nutrition room refrigerators had encrusted residue, indicating non-compliance with cleaning policies.
The facility failed to maintain a clean and safe environment, affecting 83 residents. Observations included a drafty window, non-cleanable surfaces, and detached wastewater lines. Laundry and utility rooms were heavily soiled, with missing cabinet doors and non-functional lights. The facility's maintenance system was not fully implemented, contributing to these issues.
A facility failed to accurately complete an MDS assessment for a resident with legal blindness. The resident's vision was incorrectly documented as 'impaired' instead of 'severely impaired'. Observations showed the resident required assistance to locate food on his tray, confirming severe vision impairment. The MDS Coordinator admitted the error after reviewing the MDS manual.
A facility failed to complete a Level II PASARR screening for a resident with mental health diagnoses, despite indications from a prior assessment. The resident's medical record lacked the necessary DCH-3878 form, and the social worker responsible could not explain the oversight.
The facility failed to develop and update care plans for two residents, leading to deficiencies in their care. A resident with infective bursitis was not informed about their treatment duration or involved in care planning. Another resident, who is legally blind, had a care plan lacking interventions for their visual impairment. Staff were observed assisting the blind resident with locating food, but necessary interventions were missing from the care plan and Kardex.
A facility failed to provide appropriate communication devices for a legally blind resident, resulting in a deficiency. The resident, with multiple diagnoses including legal blindness, struggled to locate food on his tray. Although staff verbally guided him, no formal interventions were documented in his care plan. Interviews with staff revealed an oversight in updating the care plan with necessary interventions, highlighting a deficiency in care practices.
A resident with multiple health conditions, including rheumatoid arthritis, did not receive the recommended Range of Motion (ROM) services after being discharged from physical therapy. The facility lacked a restorative program, and the task for passive ROM was not activated, resulting in no documented ROM exercises for the resident in the past month.
A resident with severe cognitive impairment eloped twice from a facility due to an inadequate alarm system on the 200 hallway door. The alarm on the door's push bar was too faint to be heard from the nurses' station, and a louder alarm had been disconnected during a system installation. The Maintenance Director believed the push bar alarm was sufficient, and the Nursing Home Administrator was unaware of the disconnection until after the incident.
A resident was using an over-the-counter inhaler, Primatene Mist, without a physician's order, contrary to the facility's policy. The resident's medical record lacked documentation for this medication, which was used daily. The Director of Nursing confirmed that all over-the-counter medications require a physician's order, which was not obtained in this case.
A resident was found with two inhalers on their over-bed table without a physician's order or a self-administration assessment. The facility's policy requires an interdisciplinary team assessment and a care plan for self-administration, which were not completed.
A facility failed to follow infection control practices for a resident's oxygen tubing, which was found undated and on the floor. Despite policy requiring weekly changes and documentation, staff could not provide evidence of compliance. The resident, with multiple health issues including COPD, was unaware of the tubing change schedule.
A facility failed to prevent physical and verbal abuse of a resident with Huntington's disease and dementia by a CNA, who struck the resident's hand and verbally abused him. The CNA lacked adequate training in abuse prevention, dementia care, and handling difficult residents, as confirmed by the DON.
Failure to Timely Report Abuse Allegation and Assess Other Potentially Affected Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement policies and procedures to ensure timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act, and to follow its own abuse policy for immediate reporting and resident protection. One resident with generalized anxiety disorder and severe cognitive impairment (BIMS score 6/15) reported to a visitor that a CNA had held her down and pushed on her during night-shift care. Nursing documentation and an incident report show that staff were alerted to this allegation late in the morning, and the NHA was notified around that time. The NHA stated she learned of the allegation around late morning to noon and began conducting much of the investigation, including interviews, before submitting the allegation to the State Agency later that night. The NHA also stated her understanding that allegations should be reported immediately but up to 24 hours, while the facility’s written abuse policy requires that all allegations of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be reported immediately but not later than 2 hours after the allegation is made. The facility’s abuse policy further requires procedures to provide the resident with a safe, protected environment during the investigation, including examining, assessing, and interviewing the resident and other residents potentially affected. The State Operations Manual Appendix PP guidance cited in the report calls for observations of the alleged victim, identification of injuries as appropriate, and assessment of interactions and relationships between staff and the alleged victim and/or other residents. Review of the facility’s abuse allegation investigation showed no evidence that other residents assigned to the implicated CNA were interviewed or assessed to determine whether they had experienced physical abuse or were otherwise potentially affected. The NHA confirmed that other residents on the CNA’s assignment were not assessed or interviewed, demonstrating a failure to follow both regulatory guidance and the facility’s own abuse policy regarding timely reporting and comprehensive assessment of potentially affected residents.
Failure to Conduct Thorough Abuse Investigation and Assess Other Potentially Affected Residents
Penalty
Summary
The facility failed to conduct a thorough abuse investigation after a resident with generalized anxiety disorder and severe cognitive impairment (BIMS score 6/15) alleged staff-to-resident physical abuse. The resident, who was later observed sleeping and able to recall that someone grabbed her legs and squeezed her ankles without further detail, had reported to a visitor that she was being held down and pushed on by a CNA during night-shift care. A nurse’s note and an incident report documented that, late in the morning, staff were alerted that the resident reported being held down by a staff member on night shift, and a witness statement recorded that the resident reported the CNA had been pushing on her during care. The allegation was discovered in the afternoon and reported to the state system that evening. The Nursing Home Administrator, who served as the abuse coordinator, stated she learned of the allegation around late morning to noon, immediately began the investigation, and conducted interviews before submitting the allegation to the State Agency later that night. The CNA identified as the alleged perpetrator confirmed she had been working that shift and was the staff member named in the allegation, and reported she was unaware of the allegation until she received a call stating the resident said she beat her. Despite facility policy and the State Operations Manual requirements that all allegations of abuse be reported immediately (but not later than two hours) and that the resident and other potentially affected residents be examined, assessed, and interviewed to ensure a safe, protected environment, the investigation documentation showed no evidence that other residents assigned to the CNA were interviewed or assessed to determine whether they had experienced physical abuse or were otherwise potentially affected.
Walk-in freezer had ongoing ice buildup and condensation over stored frozen food
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, specifically the walk-in freezer, affecting 87 residents. During the initial kitchen tour, the Food Service Director reported being in the role for about four months, and the surveyor observed several areas of ice dams appearing to come from the ceiling unit directly over open and closed cardboard boxes of frozen food items, including individual ice creams. Several ice cream containers had solid ice on the packaging, the ceiling had frozen condensation covering a large area, and there was a solid area of ice on the floor just inside the freezer door. The Food Service Director stated the freezer had a history of issues and that maintenance staff monitored it routinely. On a later observation, continued ice buildup was seen on individual ice cream containers with thin paper tops and on several boxes with frozen ice buildup located under the freezer unit. The Maintenance Director reported a long history of ice buildup in the kitchen walk-in freezer with about monthly removal of ice buildup. The Maintenance Director also stated that after ownership changed, maintenance was completed on the unit in the freezer with improvements, but ice dam buildups continued, possibly because staff moved curtains. The Maintenance Director further reported the walk-in freezer had been repaired in 10/2025 prior to the new company purchase.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure timely completion of Quarterly MDS assessments for four residents, including R8, R29, R34, and R82. Review of R8’s record showed admission with diagnoses including Alzheimer’s disease and contracture of the right hand. R8’s Quarterly MDS with an ARD of 10/7/25 indicated the BIMS was not conducted because R8 was coded as rarely/never understood, and R8 was coded with upper extremity impairments on both sides and dependence on staff for ADLs. That Quarterly MDS was completed on 10/23/25. On 02/10/2026, R8 was observed seated in a Broda chair in the dining room receiving staff assistance with lunch, and as of 02/11/2026 at 1:49 PM, R8’s Quarterly MDS with an ARD of 1/6/26 remained in progress and not completed. R29’s record reflected admission with diagnoses including dysarthria following cerebral infarction. The Quarterly MDS with an ARD of 12/24/25 was completed on 1/27/26. In interview, MDS Coordinator J reported being about one month behind on MDS assessments and stated a Quarterly MDS was to be completed within 14 days of the ARD. In a later interview, MDS Coordinator J reported being behind on scheduled MDS assessments for the past two months and stated that R34’s Quarterly MDS dated 12/30/25 was not completed until 2/10/26, and R82’s Quarterly MDS dated 1/8/26 was not completed until 2/13/26. MDS Coordinator J confirmed both R34 and R82 assessments were completed late.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat 2 residents with dignity and respect. R7, a cognitively intact male with spastic quadriplegic cerebral palsy, dystonia, polydipsia, bilateral hand contractures, and depression, was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers, and eating. During multiple observations, R7 was lying in bed with his soft touch call light on the floor between the bed and wall and out of reach, including while staff were at bedside assisting with meals and after staff had left the room. R7 reported he could usually reach the call light if it was positioned for him, but at the time he could not reach it, and he stated that some staff were not patient while listening to his needs because it takes him a long time to verbalize them. His care plan directed staff to keep the call light within reach and provide prompt response to requests for assistance. R19, who had diagnoses including cerebral infarction, polyneuropathy, bladder disorder, anxiety, left side hemiplegia, and hemiparesis, had intact cognition per MDS. During an observation and interview, R19 reported the facility had run out of his medium-sized briefs and he had to wear extra-large briefs that were ill fitting and uncomfortable. A CNA confirmed that the facility had run out of resident supplies such as briefs and wipes and that when a preferred size was unavailable, residents might have to wear a different size, such as extra-large instead of medium.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform three residents of the benefits, risks, and alternatives for prescribed psychotropic medications. For one resident with Alzheimer’s disease, contracture of the right hand, and dependence on staff for ADLs, the record showed orders for Seroquel 25 mg twice daily and Lorazepam 2 mg twice daily, but no consent for either medication was documented. The resident was observed seated in a Broda chair in the dining room receiving staff assistance with lunch, and the Regional Director of Operations stated she did not personally look for the psychotropic medication consents and reported there were issues with the consent process. For another resident with Huntington’s disease, dementia, and depression, the record showed orders for Mirtazapine 15 mg at bedtime, Lorazepam 1 mg daily, Lorazepam 2 mg at bedtime, and Seroquel 100 mg three times daily, but no consents for these psychotropic medications were found in the chart. A Social Worker confirmed there were no psychotropic medication consents in the record. For a cognitively intact resident with end stage renal disease, paranoid schizophrenia, schizoaffective disorder, depression, anxiety, insomnia, and other diagnoses, the record showed orders for Aripiprazole 15 mg daily, Olanzapine 15 mg daily, Sertraline 25 mg at bedtime, and Trazodone 100 mg at bedtime, and no consents were documented for these medications in the medical record.
Incomplete SNF-ABN Forms for Three Residents
Penalty
Summary
The facility failed to provide completed Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) forms for three residents, identified as R41, R45, and R86, out of three residents reviewed. The forms reviewed for each resident stated that beginning on a specified date, the resident may have to pay out of pocket for care if no other insurance covered the costs, and listed services including Physical Therapy, Daily Skilled Nursing Care, Occupational Therapy, and Room and Board. For each of the three SNF-ABN forms, the estimated cost line was left blank, with no dollar amount entered to show the resident's cost for the listed items or services. R41 signed the form on 12/11/25, R45 signed on 1/9/26, and R86 signed on 1/22/26. During interview, the Business Office Manager explained that the SNF-ABN is obtained after a resident has been cut from Medicare services and after a NOMNC is given, and stated that the form should include the resident's name, date, last covered date, and a daily rate if private pay or based on secondary insurance. She also stated that the daily rate information would be important for the resident to have to make a decision on whether to continue services.
Failure to Notify Representatives of Bed-Hold Policy and Transfer Reason
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative of the facility's bed-hold policy and failed to provide a written reason for transfer for two residents who were hospitalized. Resident #1 was a female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and vascular dementia. Her MDS showed severely impaired ability to make daily decisions and dependence on staff for dressing, mobility, transfers, hygiene, bathing, toileting, and oral hygiene. Her EMR reflected that she was transferred to the hospital, but there was no evidence that her responsible party was given written notification of the bed-hold policy or the reason for transfer. Resident #64 was a female with diagnoses including dementia, urinary tract infection, and spinal stenosis. Her MDS showed severely impaired ability to make daily decisions and need for staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting. She was observed in bed, pleasantly confused, and not oriented. Her EMR reflected a hospital transfer, but there was no evidence that her responsible party received written notification of the bed-hold policy or the reason for transfer. The DON stated staff were expected to complete transfer notice, SBAR, and a progress note, and that documents were sent with the resident and provided to EMS, but the DON was unable to provide evidence that either resident's responsible party received a physical copy of the transfer notice and bed-hold information.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure timely completion of comprehensive MDS assessments for three residents, including R114, R50, and R59. R114 was admitted with diagnoses including an ocular laceration of the left eye, diabetes, CHF, and COPD. The admission MDS for R114 had an ARD of 2/3/26 and was still in progress and not completed as of 2/12/26 at 9:29 AM. R114 was observed lying in bed on 2/10/26 at 11:22 AM. During interview, the MDS Coordinator reported being about one month behind on MDS assessments and stated that admission MDS assessments were to be completed within 14 days of admission, counting the admission date as day one. The MDS Coordinator also reported being behind on scheduled MDS assessments for the past two months and that several were incomplete due to being busy and not having been able to catch up. The annual comprehensive MDS for R50, dated 1/9/26, should have been completed by 1/23/26 and was still incomplete, and the annual comprehensive MDS for R59, dated 12/29/25, should have been completed by 1/12/26 and was also still incomplete.
Late Completion of Significant Change MDS Assessment
Penalty
Summary
The facility failed to ensure timely completion of a comprehensive significant change MDS assessment for one resident. The resident was a male with diagnoses including spastic quadriplegic cerebral palsy, dystonia, polydipsia, bilateral hand contractures, and depression. His MDS reflected a BIM score of 14, indicating he was cognitively intact for daily decision-making, and that he was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers, and eating. Review of the electronic medical record showed the significant change MDS assessment was dated 1/2/26 and remained in progress, meaning it was incomplete. During interview, the MDS Coordinator stated the assessment should have been completed within 14 days and was currently late, and reported there were several late MDS assessments that were being brought up to date.
Baseline Care Plan Missing Pertinent ADL Needs
Penalty
Summary
The facility failed to formulate a Baseline Care Plan that included pertinent care needs for one resident, R114, within 48 hours of admission. R114 was admitted with diagnoses including ocular laceration of the left eye, diabetes, congestive heart failure, and chronic obstructive pulmonary disease. The admission MDS with an ARD of 2/3/26 was still in progress and not completed as of 2/12/26. R114 was observed lying in bed on 2/10/26 and later observed being propelled in the hallway in a wheelchair by staff on 2/12/26. The resident’s Care Plan had a focus area for assistance with daily care needs, with the goal initiated on 1/29/26, but interventions were not added until 2/11/26, and those interventions included assistance of two people for bathing, bed mobility, toileting, and transfers, along with setup assistance for eating/meals. The DON stated nurses completed initial care planning, then nurse managers and the IDT reviewed them, and that MDS was consulted in the Care Plan process; the DON also stated it was her expectation that ADL Care Plans included bathing/showering level of assistance, oral care, toileting, transfer status, bed mobility, and eating.
Incomplete and Untimely Care Plans for Dialysis, ADL Support, and Foley Catheter Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents. One resident was admitted with end stage renal disease, multiple chronic conditions including CHF, COPD, schizophrenia, depression, anxiety, gout, hypertension, atrial fibrillation, and dialysis dependence. Although the resident had a physician order for dialysis three times per week and the care plan included a dialysis-related problem and intervention, the intervention section remained blank and did not document the resident’s dialysis schedule, departure and return times, or transportation method. The DON confirmed the dialysis care plan intervention was not completed and could not explain why it remained blank. A second resident with lumbar spinal stenosis and a BIMS score of 15 had an ADL self-care performance deficit care plan that included only limited interventions such as glasses use, foot positioning, and education about non-compliance with ADL care. The DON stated the care plan should have included bathing or showering assistance, oral care, toileting, transfer status, bed mobility, and eating, and acknowledged the plan was not comprehensive. A third resident with dementia, urinary tract infection, and spinal stenosis had severe cognitive impairment and required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting. The resident had a Foley catheter in place, but the care plan did not include catheter care until it was added later, and the UM confirmed it was not added timely despite expecting it to be reflected in the care plan.
Failure to Monitor Vital Signs and Assess Respiratory Status
Penalty
Summary
The facility failed to follow Physician Orders for vital signs monitoring for a resident admitted with diagnoses including ocular laceration of the left eye, diabetes, CHF, and COPD. The resident’s February 2026 MAR reflected an order for vital signs to be monitored twice daily and as needed, and the order was signed out as completed twice daily; however, vital signs information was not recorded. By 2/12/26, the medical record showed temperature, pulse, respiratory rate, and oxygen saturation were documented only four times between 1/28/26 and 2/9/26, while blood pressure was documented 15 times between 1/28/26 and 2/12/26. The facility also failed to assess and monitor respiratory status when administering an as-needed albuterol nebulizer treatment for shortness of breath. The MAR reflected an order for Albuterol Sulfate Inhalation Nebulization Solution every six hours as needed, and it was administered on 2/6/26 at 8:33 PM and documented as effective. However, the resident’s record did not include documentation of a respiratory assessment before or after the treatment. The resident reported episodes of shortness of breath, including being told to return to their room and rest after becoming short of breath in the therapy gym, and stated that a requested breathing treatment was not provided. The DON stated the expectation was to obtain vital signs and assess lung sounds and oxygen saturation before and after administration of the nebulizer treatment.
Failure to Provide Ordered ROM for Resident With Contractures
Penalty
Summary
The facility failed to implement interventions to prevent the development and/or worsening of contractures for one resident with Huntington's Disease, dementia, and depression. The resident's annual MDS reflected short- and long-term memory impairment and dependence on staff for ADLs, and it also indicated no upper or lower extremity impairments that interfered with daily function or placed the resident at risk for injury in the prior seven days. However, the resident was observed seated in a Broda chair with a hoyer lift sling beneath them and both knees in a flexed position, later observed in an activity with eyes closed and knees flexed, and later observed in bed lying on their left side with knees flexed beneath the linens. The medical record included a task and physician's order requiring active and passive ROM with ADL care, but there was no documentation that ROM had been provided within the prior 30 days. The CNA care guide also directed active and passive ROM with ADL care. During interview, an LPN stated the facility had started a list of residents with contractures and that this resident was on the list, with ROM to begin later. A CNA reported the resident's lower extremities were contracted and had worsened over the prior six months, that the resident kept their knees flexed throughout the day, and that only stretching during dressing and care was being done rather than a ROM program with repetition. The DON stated the resident's arms and legs could not fully extend and that passive ROM was needed, and described expectations for ROM, assessment, monitoring, and documentation that were not reflected in the record.
Failure to Provide Palatable and Appealing Meals
Penalty
Summary
The facility failed to consistently provide palatable food for one resident, R19, who was admitted with diagnoses including cerebral infarction, polyneuropathy, bladder disorder, anxiety, left side hemiplegia, and hemiparesis. R19’s MDS assessment showed a Brief Interview for Mental Status score of 14/15, indicating intact cognition. During lunch observation, R19 was served a corn dog, yellow squash, and cold pasta with elbow macaroni. R19 stated that corn dogs had been served twice in the same week, the squash was overcooked and difficult to pick up with a fork, and the food lacked flavor and variety. R19 also reported that condiments were often not provided, and no salt or pepper was observed on the tray at that time. R19 further reported that food was sometimes delivered cold and late on weekends. During another lunch observation, R19 was served a cheeseburger with cheese only, coleslaw, and juice, and stated that burgers used to be made to order with additional toppings such as onions and tomatoes, but that was no longer offered. R19 also reported that hamburger and grilled cheese sometimes caused diarrhea. No condiments were observed on the tray except salt and pepper, and R19 stated he did not eat the coleslaw because it had also been served with dinner the night before. Review of the grievance log from August 2025 through January 2026 showed food-related concerns including cold food and paper plates with no desserts.
Improper Dumpster and Waste Disposal
Penalty
Summary
Improper disposal of garbage and refuse was identified when surveyors observed four dumpsters outside the facility, including a new yellow trash dumpster with several items around it and full bags of trash on the ground. During the initial kitchen tour, the Food Service Director reported that the facility had recently changed ownership and that the prior garbage company had not yet picked up the dumpsters. The Food Service Director also stated that all trash should be placed in dumpsters and that lids should be closed, while maintenance was responsible for maintaining the trash receptacles. The Maintenance Director later stated that the facility had communicated with the prior garbage company since the ownership change but the two full dumpsters had still not been removed, and that items, including large furniture, had been left outside the dumpster area during heavy snow. Review of communication with the prior dumpster company showed no follow-up or communications between 12/3/25 and the survey entrance on 2/10/26 regarding removal of the prior company dumpsters.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to ensure accurate documentation for one resident’s medical record. Resident #64 was a female with diagnoses including dementia, urinary tract infection, and spinal stenosis, and her MDS reflected severely impaired decision-making and dependence on staff for dressing, mobility, transfers, hygiene, bathing, and toileting. On 2/10/2026, during an observation, she was in bed with two staff assisting with care, appeared pleasantly confused, and an LPN discussed changing a wound dressing while wound supplies were at the bedside. The LPN turned the resident and looked for the wound, then stated the wound must have healed because it could not be located and left the room with the wound supplies. Review of the MAR showed an order for Medihoney wound/burn dressing gel to the coccyx daily with cleansing and foam dressing, and the LPN had signed the wound care as completed. However, the progress notes had no linked documentation related to the MAR, and a wound care consult from the day before documented a facility-acquired unstageable pressure wound to the coccyx measuring 2.3 cm by 7.5 cm. During interview, the LPN stated she did not complete the wound care because she could not locate the wound and believed the order was old and should have been removed from the MAR. The RN reported the treatment had been completed on night shift, while the wound nurse stated the resident definitely had the wound on 2/10/26 and that if treatment was not completed, staff should document it as not completed rather than completed. The DON stated staff should follow physician orders and that documenting treatment as completed when it was not done would be falsification of medical records.
Failure to Administer Oral Chemotherapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including aphasia, esophageal cancer, and vascular dementia did not receive their prescribed oral chemotherapy medication, capecitabine, for approximately 30 days. The resident was admitted with orders for capecitabine to be administered in cycles, but a review of the clinical record revealed a gap in active orders for the medication from early July to early August. During this period, the medication was not administered, as confirmed by the Medication Administration Record, which showed no doses given between the evening of July 4th and August 4th. There was no documentation or physician order indicating that the medication should have been stopped, and the resident’s family reported that the oncologist was able to determine the medication had not been provided during a follow-up appointment. Interviews with facility staff, including the DON and ADON, revealed that the process for reviewing medication changes after outside appointments relies on paperwork being returned and reviewed by the receiving nurse. However, no documentation was found to support discontinuation of the chemotherapy, and the facility could not provide medication error reports for the resident. The gap in medication administration was attributed in part to the termination of the nurse practitioner who had written the previous order, but no further explanation was provided for the lapse in care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the experiences of four residents. Resident #2, who is cognitively intact, reported being left soiled for extended periods due to understaffing and long call light response times. Resident #3, also cognitively intact, experienced delays of over 15 minutes for call light responses at night. Resident #8, with moderate cognitive impairment, reported waiting up to two hours for assistance with incontinence care, particularly during the day shift. Resident #9, also with moderate cognitive impairment, experienced a four-hour delay in call light response for assistance with a hoyer lift transfer and was left wet and soiled without staff checking on them regularly. Interviews with Certified Nurse Aides (CNAs) revealed that they were assigned 14 to 15 residents each, making it challenging to provide timely care. CNAs reported being able to check and change incontinent residents only once or twice in an eight-hour shift, despite the expectation of every two hours. The Director of Nursing (DON) was unaware of any concerns regarding call light response times or residents being left wet or soiled, and the facility lacked the capability to run reports on call light response times. This deficiency highlights the facility's failure to ensure adequate staffing levels to meet the care needs of residents, resulting in prolonged periods of incontinence and delayed assistance.
Deficiencies in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain and clean food service equipment, which affected 83 residents and increased the likelihood of cross-contamination and bacterial harborage. During a comprehensive tour of the food service area, several deficiencies were observed. The walk-in freezer had a weak automatic door closer assembly, preventing the door from closing completely. The Victory one-door reach-in cooler had a worn, torn, and missing door gasket. Two fry pans were found etched, scored, and with particulate. Additionally, the dry storage room and food production kitchen had overhead light assembly lens covers with dead insect carcasses. Further observations revealed that the walk-in freezer's refrigeration unit had ice protruding from the Freon supply lines and unit cabinet. Several pieces of equipment, including the South Bend convection oven, Vulcan stove/oven, Legion tilt kettle, juice machine, and Univex stand mixer, were heavily soiled with accumulated and encrusted food residue. The drywall surface adjacent to the Evolution steamer was etched, scored, moist, and particulate, and the wall/floor vinyl coving strip was loose-to-mount. In the nutrition rooms, the Amana refrigerator's interior door gasket and freezing compartment door gasket were soiled with accumulated and encrusted food residue. Similarly, the Whirlpool refrigerator and freezing compartments in the long-term care nutrition room were observed with accumulated and encrusted food residue, and the door gaskets were also soiled. These observations indicate a failure to adhere to the facility's policies and procedures for cleaning equipment and utensils, as well as food safety requirements.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and the public, affecting 83 residents. Observations revealed several deficiencies, including a drafty and leaking window in a resident's room, which could not be shut completely, allowing cold air to enter. In the 300 Hall, a chair backrest was covered with black duct tape, with Styrofoam padding protruding, creating a non-cleanable surface. Additionally, the 300 Hall Shower Room had a detached wastewater connection line, causing wastewater to flow onto the floor. The 100 Hall Shower Room had missing base cabinet doors and loose wall/floor vinyl coving, while the facility's laundry service areas were heavily soiled with dust, dirt, and cobwebs. Further deficiencies were noted during an environmental tour with the Environmental Services Manager. The 100 Hall/200 Hall Soiled Utility Room had dead insect carcasses in the overhead light assemblies, and the waste caddy was heavily soiled. The Clean Utility Room had missing cabinet doors and soiled landing strips. The 300 Hall/400 Hall Clean Utility Room had non-functional fluorescent light bulbs, and the Nursing Station had damaged laminate flooring. The facility's maintenance work order system, TELS, had not been fully implemented, contributing to these issues. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the numerous maintenance and cleanliness issues observed.
Inaccurate MDS Assessment for Legally Blind Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #39, who was admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, and legal blindness. The MDS assessment, with an Assessment Reference Date (ARD) of 11/08/2024, incorrectly documented the resident's vision status. The MDS Coordinator recorded the resident's vision as 'impaired' when it should have been documented as 'severely impaired' due to the resident's legal blindness. Observations and interviews revealed that the resident was unable to see and required assistance to locate food on his tray, indicating a severe impairment in vision. The MDS Coordinator acknowledged the error upon review, confirming that the resident's vision should have been coded as 'severely impaired' according to the MDS manual guidelines. This inaccuracy in the MDS assessment was identified during a survey, highlighting a deficiency in the facility's assessment process.
Failure to Complete Level II PASARR Screening
Penalty
Summary
The facility failed to coordinate and complete a Level II screening for a resident reviewed for Preadmission Screening/Annual Resident Review (PASARR). The resident, who was admitted to the facility with multiple diagnoses including PTSD, bipolar disorder, and paranoid schizophrenia, had a PASARR completed that indicated the need for a Level II screening due to the presence of mental illness and treatment with antipsychotic or antidepressant medications. However, the medical record did not contain the required DCH-3878 Level II form. During an interview, the social worker confirmed the absence of the Level II DCH-3878 in the resident's medical record and acknowledged that it was her responsibility to ensure its completion. Despite this, she could not provide an explanation for the oversight. The deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's process for coordinating necessary assessments for residents with mental health conditions.
Deficiencies in Care Plan Development and Updates
Penalty
Summary
The facility failed to develop and update individualized care plans for two residents, leading to deficiencies in their care. Resident #181 was admitted with a diagnosis of infective bursitis and was receiving intravenous antibiotic therapy. Despite being cognitively intact, the resident reported not being informed about the duration of their treatment or involved in care planning. The social services technician confirmed that a care conference had not been scheduled for this resident, which was an oversight. Resident #39, who is legally blind, had a care plan that lacked specific interventions to assist with their visual impairment. The resident was observed struggling to locate food on their tray, and staff were seen guiding the resident's hand to the food. The MDS Coordinator acknowledged that the care plan and Kardex did not include necessary interventions for the resident's blindness, which was an oversight. The Director of Nursing confirmed the absence of interventions and could not explain the omission.
Deficiency in Care for Legally Blind Resident
Penalty
Summary
The facility failed to provide appropriate alternative communication devices for a resident who was legally blind, leading to a deficiency in care. The resident, admitted with multiple diagnoses including legal blindness, was observed struggling to locate food on his tray due to his visual impairment. A Certified Nurse Aide was seen guiding the resident's hand to his food and verbally explaining its location, but no formal interventions were documented in the resident's care plan or Kardex to assist with his blindness. The resident's care plan did mention the availability of an adaptive communication device, but the resident denied using such a device and was unable to explain how staff communicated with him regarding the location of items he could not see. Interviews with facility staff, including an LPN, the MDS Coordinator, and the Director of Nursing, revealed a lack of documented interventions to assist the resident with his blindness. The MDS Coordinator acknowledged the oversight in updating the resident's care plan with necessary interventions, and the Director of Nursing confirmed that the absence of these interventions did not meet her expectations for care. Despite the resident's ability to communicate verbally, the lack of documented strategies to address his visual impairment was identified as a deficiency in the facility's care practices.
Failure to Provide Range of Motion Services
Penalty
Summary
The facility failed to provide Range of Motion (ROM) services to a resident, identified as R59, to prevent the possibility of decreased ROM and mobility. R59 was admitted with multiple diagnoses, including rheumatoid arthritis and polyarthritis, and was cognitively intact. During an observation and interview, R59 reported that skilled therapy services had stopped and denied receiving any ROM exercises for his extremities. The medical record indicated that there were physician orders for daily skilled care, including physical and occupational therapy, but these services were discontinued as R59 no longer qualified for them. The discharge summary from physical therapy recommended a restorative program for ROM, which was not implemented. The Director of Rehabilitation confirmed that R59 did not receive a restorative program due to its unavailability at the facility. The Director of Nursing explained that while CNAs were supposed to perform ROM during activities of daily living, the specific task for passive ROM had not been activated for R59. A CNA further explained that ROM is completed for residents listed on their Task Care Record, but R59's record did not show any completion of the CNA Maintenance Program for passive ROM in the last thirty days. This lack of implementation of the recommended ROM program led to the deficiency identified in the report.
Inadequate Alarm System Leads to Resident Elopement
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident with severe cognitive impairment due to dementia. The resident, who scored 5 out of 15 on the Brief Interview for Mental Status (BIMS), eloped from the facility twice. The first incident occurred on July 9, 2024, when the resident was found approximately 100 yards from the building. The second incident took place on November 16, 2024, when the resident exited through the 200 hallway door and was later found near the facility's dumpsters. During the investigation, it was discovered that the alarm system on the 200 hallway door was inadequate. The alarm installed on the door's push bar was faint and could not be heard from the nurses' station or the television lounge area. This issue was confirmed by staff members who were present at the time of the incident and by the surveyor who tested the alarm. The louder alarm, which would sound if the door was fully opened, had been disconnected during the installation of the delayed egress alarm. The Maintenance Director admitted that the louder alarm was disconnected during the installation of the new system and was not reconnected because he believed the push bar alarm was sufficient. The Nursing Home Administrator was unaware of the disconnection until after the elopement incident on November 16, 2024. The deficiency was identified during an onsite survey, highlighting the facility's failure to maintain an effective alarm system to prevent resident elopement.
Failure to Obtain Physician Order for Over-the-Counter Medication
Penalty
Summary
The facility failed to adhere to its pharmacy policy and acceptable clinical practice regarding medication usage and administration for one resident. The resident, who was admitted with multiple diagnoses including COPD, stroke, and dementia, was observed using an over-the-counter inhaler, Primatene Mist, which was not documented in their medical record. The resident's wife had purchased the inhaler, and the resident used it daily without a physician's order specifying the medication's name, dosage, route, and frequency, as required by the facility's policy. During an interview, the Director of Nursing confirmed that all over-the-counter medications, including Primatene Mist, require a physician's order. The facility's policy on non-controlled medication order documentation mandates that medications are administered only with a clear, completed, and signed order from a licensed prescriber. The policy specifies that medication orders must include the name, strength, dose, dosage form, frequency, route of administration, and quantity or duration of therapy. The absence of a physician's order for the resident's use of Primatene Mist constituted a failure to comply with these requirements.
Improper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure proper medication storage for a resident, identified as Resident #54, who was observed with two inhalers on the over-bed table. The resident had a Primatene Mist inhaler, purchased by his wife, and an Albuterol Sulfate inhaler, which was prescribed as a rescue inhaler. The resident could not specify the frequency of use for either inhaler. The facility's Licensed Practical Nurse (LPN) confirmed that residents could keep medications at their bedside only with a physician's order and a care plan specifying self-administration, neither of which were present for this resident. The Director of Nursing (DON) explained that a self-administration assessment and a physician's order were required for residents to self-administer medications and keep them at their bedside. However, there was no documentation of such an assessment or order in the resident's medical record. The facility's policy on self-administration of medication required an interdisciplinary team assessment and a care plan reflecting self-administration and storage arrangements, which were not completed for this resident.
Failure to Implement Infection Control Practices for Oxygen Tubing
Penalty
Summary
The facility failed to implement proper infection control practices regarding the replacement of oxygen tubing and nasal cannulas for a resident. The resident, who was admitted with multiple diagnoses including COPD, stroke, and chronic respiratory failure, was observed with undated oxygen tubing and a nasal cannula on the floor. The resident reported wearing oxygen only when necessary and was unaware of how often the tubing was changed. Observations on two separate occasions confirmed the tubing was undated and on the floor. Interviews with facility staff, including an LPN and the DON, revealed that the policy required weekly replacement of oxygen tubing, with documentation in the Medication Administration Record (MAR). However, the DON could not provide evidence of an order for the resident's tubing to be changed weekly, nor was there documentation of such changes in the MAR. The facility's policy, last revised in June 2024, mandates weekly changes of oxygen tubing and documentation in the electronic health record, which was not adhered to in this case.
Failure to Prevent Abuse and Provide Adequate Training
Penalty
Summary
The facility failed to provide an environment free from physical and verbal abuse for a resident diagnosed with Huntington's disease, dementia, and other conditions. The incident involved a Certified Nursing Aide (CNA) who was reported to have struck the resident's hand with an open brief and verbally abused the resident by calling him a 'bad man' and 'mean.' This was observed by another CNA during a care session where the resident exhibited aggressive behavior. The incident was reported to the Nursing Home Administrator (NHA), who initiated an investigation and reported it to the Michigan Facility Reported Incidents (MI-FRI) system. However, the NHA did not substantiate the abuse in the final report despite terminating the CNA involved for abuse. The investigation revealed that the CNA involved had not received adequate training in abuse prevention, dementia care, or handling difficult residents. The Director of Nursing (DON) confirmed the lack of documentation for such training during the hiring process and noted that the last abuse education for the CNA occurred two months prior to the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, but it was evident that the policy was not effectively implemented, as the CNA's personnel file did not demonstrate the required training and education to prevent such incidents.
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What surveyors actually found near you
We read the 743 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ypslianti
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Parkridge | 2.6 mi | ★★★★★ | 16 | 0 |
| The Gilbert Residence | 2.7 mi | ★★★★★ | 10 | 0 |
| Optalis Health And Rehabilitation Of Ann Arbor | 3.7 mi | ★★★★★ | 2 | 0 |
| Glacier Hills | 4.5 mi | ★★★★★ | 0 | 0 |
| Regency At Canton | 5.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.