The Willows at Howell

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 03/30/2026 at 8:47 AM observed raw pork stored in a pan on the top shelf of the rack, positioned above pre sliced packaged meats in the walk-in cooler. Director of Food (DOF) G indicated they were unaware why it was stored there.On 03/30/2026 at 8:49 AM observed a pan of raw chicken on the bottom shelf of a rack in the walk-in cooler. Stacked metal pans were beside the raw chicken with a facility label indicating raw chicken. When the lid was removed cooked chicken was observed inside the stacked pans. DOF G removed the pans from their location. An interview at this time with DOF G found that the chicken was for lunch and indicated that was an educational piece for staff.On 03/30/2026 at 11:18 AM observed a poster on the walk-in cooler door labeled Proper Food Storage. Indicating appropriate storage locations for poultry, ground meat,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to appropriately store and label food items in the kitchen and a reach-in refrigerator. This deficient practice had the potential to affect all residents that consume food in the facility out of a total census of 55. Findings include: On 01/21/25 at approximately 8:53 a.m., a tour of the facility kitchen was conducted with kitchen manager A (KM A) and the following was observed: 1. A tray of uncovered/unprotected apple cinnamon deserts was observed in the walk-in refrigerator with a preparation date of 1/16/25 and use by date of of 1/19/25. 2. A tray of uncovered/unprotected and dried out meat patties was observed in the walk-in refrigerator. 3. A tray of previously cooked personal sized pizzas were observed uncovered and had no dating/labeling on them in the walk-in refrigerator. 4. An uncovered pan of Blueberry desert that had a preparation date of 1/16/25 with a use by date of 1/18/25 was observed in the walk-in refrigerator. On 1/21/25 at approximately 9:03 a.m., during a conversation with KM A, KM A was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for six (R8, R16, R17, R40, R41, and R44) of eight residents reviewed for resident assessments. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html: .The Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days (ARD of most recent OBRA assessment +92 days) after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior Comprehensive or Quarterly assessment) AND The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . Review of the triggered resident assessment task identified there were eight resident MDS assessments noted as having an MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for one (R26) of three residents reviewed for beneficiary notification, resulting in the resident not being informed timely of private pay charges for continued services at the facility, and the inability to file an appeal. Findings include: Review of the beneficiary notification documentation provided for three randomly selected residents included R26. Upon further review of the documentation for R26, concerns were identified that the facility issued a NOMNC (Notice of Medicare Non-Coverage) on 9/11/24, which was the same date of the resident's last covered day. R26 and/or their responsible party were not provided adequate notice of the non-coverage, in the event the responsible party wanted to request an appeal of this decision. Additionally, R26 remained in the facility following the facility's decision to end skilled services, without the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for two (R1 and R37) of eight residents reviewed for resident assessments. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html: .At a minimum, facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident. For the purpose of this guidance, not less than once every 12 months means within 366 days . Review of the triggered resident assessment task identified there were eight resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required. Two of the eight residents identified these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to utilize proper personal protective equipment (PPE) for COVID-19 transmission-based precautions (TBP) and ensure signage outside of the room included accurate instructions for PPE for two (R6 and R210) of two residents reviewed for TBP. Findings include: On 1/21/25 at 9:41 AM, signage was observed on the door of R6's room that indicated R6 was on droplet precautions. The sign noted that those who entered R6's room must clean their hands, and ensure eyes, mouth, and nose were fully covered before entry into the room. The visuals on the signage showed a person wearing a surgical mask and either a face shield or goggles. A bin was observed outside of R6's room that contained gloves, goggles, surgical masks, and KN95 masks. There were no N95 respirator masks located in the bin. At that time, Registered Nurse (RN) 'G' was observed exiting R6's room wearing a surgical mask. At that time, RN 'G' was queried about why R6 was on droplet precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147778. Based on interview and record review, the facility failed to notify one resident (R801) of three reviewed for discharge, reason of discharge in writing and manner they understand including a thirty day advance notification, and statement of resident's right to appeal. Findings include: On 10/30/24 a complaint was received by the State Agency (SA) alleging the facility failed to provide a thirty-day notice of discharge from to R801. Clinical record review revealed R801 resided as a long-term resident admitted to the facility on [DATE]. R801 had an extensive substance abuse history for alcohol misuse and required multiple inpatient hospitalizations and rehabilitation placements. Psychiatric diagnoses included bipolar and anxiety. Medical history included chronic kidney disease, pulmonary disease, hypothyroid and low blood pressure. Recent medical diagnosis included left elbow bursitis requiring orthopedic and infection control management. R801 was legally blind and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to intake MI00143514. Based on interview and record review the facility failed to follow their transmission-based precautions for one resident (R900) of three residents reviewed for infection control. Findings include: Review of the complaint filed with the State Agency on 3/21/2024 documented in part My mother, (R900's name), was transferred to (facility's name) after a hospital stay for rehab. On day 6 of her stay she was put under isolation precautions due to pneumonia/mrsa (Methicillin-resistant Staphylococcus aureus-a contagious bacterial infection). She was not on precautions at the facility prior to that. There was no explanation given to her, they hung the sign on the door and closed her door . The executive director called me and stated the mrsa diagnosis was not in the original paperwork from the hospital . My mom was all over the facility for the 6 days she was there. She went to therapy, the dining room, activities, we walked the halls. Review of the clinical record revealed R900 was admitted into the facility on 3/12/2024 with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain sanitary equipment, maintain equipment and plumbing in good repair, and properly date mark potentially hazardous foods, resulting in the potential for increased risk of foodborne illness, affecting all residents in the facility. Findings include: On 3/18/24 at 9:12 AM, during an inspection of the kitchen, food debris was observed to be accumulating in the utensil drawer across from the cookline. At this time, Director of Food Service (DFS) N instructed a staff member to clean the utensil drawer. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 3/18/24 at 9:15 AM, four cutting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one resident (R3) was assessed for safe self-administration of medication of one residents reviewed for self-administration, resulting in the potential for inappropriate administration of medication. Findings include: On 3/19/24 at approximately 9:33 a.m., R3 was observed in their room, laying in their bed. R3 was observed to have a bottle of fluticasone propionate nasal spray and a bottle of Carboxymethylcellulose 0.5% eyedrop solution on the bedside table in front of them. R3 was queried regarding the medications observed at the bedside and they indicated that they used the nasal spray when they need it and that sometimes they will administer the eyedrops and sometimes the Nursing staff will administer them. On 3/19/24 at approximately 12:40 p.m., R3 was observed in their room, laying in their bed. R3 was still observed to have the fluticasone and Carboxymethylcellulose eyedrops on their bedside table in front of them. On 3/19/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Physician ordered medication was appropriately ordered and administered for one resident (R217) of one residents reviewed for Nursing standards, resulting in a delay in pain medication being available for administration. Findings include: On 3/18/24 at approximately 12:21 p.m., R217 was observed in their room, laying in their bed. R217 was queried if they had any concerns regarding their admission process to the facility and they reported that they could not get enough pain medication and that they had missed some doses of their oxy (oxycontin) because the medication was not in the building. R217 reported that they did not understand how a medical facility did not have the right medication. On 3/19/24 the medical record for R217 was reviewed and revealed the following: R217 was initially admitted to the facility on [DATE] and had diagnoses including Left hip pain and acute proximal respiratory failure. A review of R217 progress notes revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an environment was free from accident hazards regarding storage of sharps (blood sugar testing lancets) for two (R6 and R10) of seven residents reviewed for accidents. Findings include: According to the facility's documentation provided for storage of sharps, the standard operating procedures for Use and Disposal of Sharps dated 6/1/18, reviewed 12/31/23 read, .Sharps will be handled in a manner to prevent needle-sticks and other skin cuts and punctures . This document did not address the facility's process for storage of sharps. On 3/18/24 at 12:03 PM, R10's room was observed to have a clear pencil box stored on top of the bedside dresser with shelves was observed to contain several blood glucose monitoring supplies (glucometer, glucose testing strips and lancets (sharps). On 3/19/24 at 10:03 AM, the above box of glucose monitoring supplies was observed opened (not closed) and stored on the bedside dresser with shelves. On 3/20/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility failed to monitor weights and follow physician orders for one (R32) of one resident reviewed for change of condition resulting in decreased intake and undetected weight loss. A record review revealed that R32 was admitted to the facility on [DATE]. R32's admitting diagnoses included metabolic encephalopathy, dementia, and chronic kidney disease. Based on a Minimum Data Set (MDS) assessment dated [DATE], R32 had a Brief Interview for Mental Status (BIMS) score of 1/15, indicative of severe cognitive impairment. R32 were dependent on staff assistance with their mobility and most of their Activities of Daily Living (ADLs) such as oral hygiene, eating, dressing etc. An initial observation was completed on 3/18/24, at approximately 9:35 AM. Staff started serving breakfast to resident rooms in the hallway approximately 15 minutes prior to this observation. A staff member, RN H was observed in the hallway. R32's room door was closed. RN H reported that R32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00140832. Based on observation, interview, and record review the facility failed to ensure timely follow through of an oral surgery referral for dental extractions was made for one resident (R44) of one reviewed for dental services resulting in a delay for oral surgery. Findings include: Review of the clinical record revealed R44 was originally admitted to the facility on [DATE] with admitting diagnoses included multiple sclerosis and major depression, and insomnia. According to the Minimum Data Set (MDS) assessment dated [DATE], R44 had a Brief Interview for Mental Status (BIMS) score 15/15, indicative of intact cognition. A review of the complaint received by the state agency revealed that R44 was recommended to have an emergency oral surgery follow up a few months ago and waiting for facility to set up an appointment. An initial observation was completed on 3/19/24 at approximately 11:15 AM. R44 was observed sitting in their wheelchair. R44 reported that they had a dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.