Villa at Willow Place

In the surveyor’s words

From the most serious findings on record at Villa at Willow Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 2, 2021

  This Citation Pertains To: MI 138 Based on observation, interview and record review the facility failed to 1. Implement interventions and safety measures for one resident (#2) whom was identified as being at risk for elopement of 6 residents reviewed for elopement. #2. Failed to initiate the facility's elopement protocol, failed to immediately respond to door alarm, failed to activate intercom announcement. Resulting in immediate jeopardy when Resident #2 eloped from the facility unbeknownst to staff and was found 1 hour and 11 minutes later, 0.9 miles away, which required hospital treatment, resulting in the potential for all 10 residents that have been identified to be an elopement risk, at risk for harm, injury, and or death. […]

• Actual harm, isolatedF686Oct 27, 2022

  Based on observation, interview and record review, the facility failed to accurately stage and regularly assess pressure ulcers for one (Resident #57) of four reviewed for pressure ulcers, resulting in the inaccurate staging of pressure ulcers and the ineffective treatment and unrecognized worsening of wounds. Findings include: Review of the medical record reflected R57 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, with an Assessment Reference Date (ARD) 9/20/22, reflected R57 scored two out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R57 required extensive to total assistance of one person for activities of daily living. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 87 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:During an observation and interview during the initial kitchen tour on 2/10/2026 at 9:28 AM, Food Service Director (FSD) F reported had been in role for about four months. Entered walk-in freezer with FSD F and observed several areas of ice damns that appeared to be coming from unit on ceiling directly over several open and closed cardboard boxes of frozen food items including individual ice creams. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2024

  Based on observations, interviews, and record reviews the facility failed to clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 12/09/24 at 09:25 A.M., A comprehensive tour of the food service was conducted with Dietary Manager H and Registered Dietician I. The following items were noted: Walk-In Freezer: The automatic door closer assembly was observed weak, allowing the door to not close completely. Registered Dietician I indicated she would contact maintenance for necessary repairs as soon as possible. The Victory one-door reach-in cooler door gasket was observed (worn, torn, missing). […]

• No harm, potential for more than minimal, widespreadF921Dec 11, 2024

  Based on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 12/09/24 at 10:48 A.M., One of two window sashes were observed drafty and leaking air, within resident room [ROOM NUMBER]. The drafty window sash was also observed to not shut completely, creating the cold air draft. On 12/09/24 at 12:13 P.M., The 300 Hall (Point Click Care Kiosk) chair backrest was observed covered with black duct tape. […]