A list of the most recent deficiencies for The Willows at East Lansing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-20 | 2023-10-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-20 | 2023-10-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-20 | 2023-10-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-20 | 2023-10-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-20 | 2023-10-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-20 | 2023-10-31 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-20 | 2023-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-20 | 2023-10-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-20 | 2023-10-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-20 | 2023-10-31 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-09-20 | 2023-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-10-31 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-04 | 2023-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-04 | 2023-04-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-07 | 2022-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-07 | 2022-11-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-07 | 2022-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-07 | 2022-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-07 | 2022-11-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-07 | 2022-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-07 | 2022-11-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-07 | 2022-11-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-07 | 2022-11-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-07 | 2022-11-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-10-07 | 2022-11-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-07 | 2022-11-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-07 | 2022-11-02 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-12 | 2022-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-08 | 2021-09-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-21 | 2021-08-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-21 | 2021-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-21 | 2021-08-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-21 | 2021-08-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-21 | 2021-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-21 | 2021-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-21 | 2021-08-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-21 | 2021-08-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-21 | 2021-08-09 | N |
