Inspection Reports for
The Willows at Howell
1500 Byron Road, Howell, MI, 48855
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Michigan average
Michigan average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
141% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 55
Deficiencies: 5
Date: Jan 22, 2025
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident notifications, timely resident assessments, food safety, and infection control practices.
Findings
The facility failed to provide timely Medicare non-coverage notices to residents, complete Minimum Data Set (MDS) assessments timely, properly label and store food items, and ensure proper use of personal protective equipment (PPE) for COVID-19 precautions.
Deficiencies (5)
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for one resident, resulting in lack of timely notification of private pay charges and inability to file an appeal.
F 0636: The facility failed to complete comprehensive Minimum Data Set (MDS) assessments timely for two residents, delaying required resident evaluations.
F 0638: The facility failed to complete quarterly MDS assessments timely for six residents, resulting in delayed resident status updates.
F 0812: The facility failed to properly label and store food items in the kitchen and refrigerators, including uncovered and expired foods, risking resident safety.
F 0880: The facility failed to ensure proper use of personal protective equipment (PPE) for COVID-19 transmission-based precautions and accurate signage outside resident rooms for two residents.
Report Facts
Total census: 55
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse, MDS Coordinator Support Nurse | Named in relation to delayed MDS assessments and completion |
| Nurse E | MDS Coordinator | Named in relation to delayed MDS assessments and completion |
| KM A | Kitchen Manager | Named in relation to food labeling and storage deficiencies |
| RN G | Registered Nurse | Observed wearing improper PPE for COVID-19 precautions |
| ICP H | Infection Control Preventionist | Interviewed regarding PPE requirements for COVID-19 precautions |
| Nurse C | Nurse | Interviewed regarding COVID-19 isolation precautions for resident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging the facility failed to provide a thirty-day notice of discharge to resident R801.
Complaint Details
The complaint was substantiated. It alleged the facility failed to provide a thirty-day notice of discharge to resident R801. The investigation confirmed the facility did not provide the required discharge notice or appeal rights documentation to R801, who is legally blind and could not read paperwork.
Findings
The facility failed to notify resident R801 in writing and in a manner they could understand about their discharge, including the required thirty-day advance notice and the resident's right to appeal. The facility also did not provide or read the discharge paperwork to the legally blind resident.
Deficiencies (1)
F 0623: The facility failed to provide timely notification to resident R801 of discharge, including a thirty-day advance notice and statement of the right to appeal. The discharge notice was not provided or read to the legally blind resident.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Prepared the notice of discharge forms but did not provide them to resident R801. |
| TCNA C | Transportation Certified Nurse Assistant | Transported resident R801 to orthopedic appointment and hospital; confirmed discharge paperwork was not provided. |
| Nursing Home Administrator | NHA | Spoke with resident R801 about discharge and confirmed discharge paperwork was not provided. |
| Admission Director A | Admission Director | Confirmed physical discussion of discharge with resident R801 and acknowledged paperwork was not provided. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 28, 2024
Visit Reason
The inspection was conducted in response to a complaint filed on 2024-03-21 regarding failure to implement proper transmission-based isolation precautions for a resident diagnosed with MRSA pneumonia.
Complaint Details
The complaint was substantiated. It documented that resident R900 was not placed on isolation precautions upon admission despite having MRSA pneumonia, resulting in exposure to other residents and staff. The facility delayed the contact precautions order until six days after admission.
Findings
The facility failed to implement contact isolation precautions timely for resident R900, who was admitted with MRSA pneumonia on 2024-03-12 but was not placed on contact precautions until 2024-03-18. The resident attended common areas and activities without isolation precautions, exposing others to potential infection risk.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program by not placing resident R900 on contact isolation precautions promptly upon admission with MRSA pneumonia. The resident was allowed to participate in activities and access common areas without appropriate isolation from 3/12/24 to 3/18/24.
Report Facts
Date of complaint filing: Mar 21, 2024
Date of resident admission: Mar 12, 2024
Date contact precautions ordered: Mar 18, 2024
Date of inspection: May 28, 2024
Inspection Report
Renewal
Census: 10
Capacity: 39
Deficiencies: 3
Date: Apr 22, 2024
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and regulations for The Willows at Howell facility.
Findings
The facility was found to be in non-compliance with several rules related to governing bodies, administrators, supervisors, employee provisions, and resident medication management. Specific deficiencies included incomplete service plans regarding medication administration and hospice services for residents.
Deficiencies (3)
Lack of detailed information in Resident A's and C's service plans on how anxiety is demonstrated and when medication administration is appropriate.
Resident A and C's hospice agency and role of hospice not detailed in the resident’s service plans.
Resident B’s service plan did not correctly identify medication management responsibilities between the facility and the resident.
Report Facts
Number of residents interviewed and/or observed: 10
Number of staff interviewed and/or observed: 3
Facility capacity: 39
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to monitor and follow physician orders for a resident's weight loss and decreased intake, and failure to ensure timely follow-through of an oral surgery referral for another resident.
Complaint Details
The complaint investigation focused on two residents: one with significant weight loss and decreased intake not properly monitored or managed, and another with delayed oral surgery referral and appointment scheduling. Both complaints were substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to adequately monitor and manage a resident's significant weight loss and decreased intake, including inconsistent follow-up with dietitian and physician orders. Additionally, the facility delayed scheduling an oral surgery appointment for a resident despite recommendations and communications, resulting in a prolonged wait time.
Deficiencies (2)
F 0692: Facility failed to monitor weights and follow physician orders for one resident resulting in decreased intake and undetected weight loss. The resident had severe cognitive impairment and required 1:1 feeding assistance but did not receive adequate monitoring or nutritional support.
F 0791: Facility failed to ensure timely follow-through of an oral surgery referral for one resident, causing a delay in receiving necessary dental surgery. The resident waited over eight months for an appointment despite multiple communications and recommendations.
Report Facts
Weight loss: 18.7
Average fluid intake: 398
Average intake percentage: 64
Time delay: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Observed assisting resident R32 and reported on resident's intake and condition |
| RN G | Registered Nurse | Attempted to feed resident R32 and reported on resident's intake and condition |
| CNA J | Certified Nursing Assistant | Interviewed regarding resident R32's breakfast intake |
| Speech Therapist K | Speech Therapist | Evaluated resident R32 and recommended feeding assistance |
| Clinical Consultant I | Clinical Consultant | Interviewed regarding dietitian services and resident R32's care |
| Physician L | Medical Director/Attending Physician | Interviewed regarding resident R32's weight loss and failure to thrive diagnosis |
| Facility Administrator | Interviewed regarding delay in oral surgery appointment scheduling for resident R44 | |
| Social Work Director B | Social Work Director | Interviewed regarding oral surgery referral communication and delay for resident R44 |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 20, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory standards including medication self-administration, nursing standards, accident prevention, nutrition, dental services, and food safety.
Findings
The facility had multiple deficiencies including failure to assess a resident for safe self-administration of medication, delays in pain medication availability, unsafe storage of sharps, failure to monitor weight and follow physician orders for a resident with weight loss, delayed dental surgery referral, and food safety violations such as unsanitary equipment and improper food storage.
Deficiencies (6)
F 0554: The facility failed to assess one resident for safe self-administration of medications, resulting in potential inappropriate medication administration.
F 0658: The facility failed to ensure physician ordered pain medication was available and administered timely for one resident, resulting in delayed pain control.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards by improperly storing sharps in resident rooms for two residents.
F 0692: The facility failed to monitor weights and follow physician orders for one resident, resulting in decreased intake and undetected weight loss.
F 0791: The facility failed to ensure timely follow through of an oral surgery referral for one resident, causing a delay in oral surgery.
F 0812: The facility failed to maintain sanitary kitchen equipment, maintain plumbing in good repair, and properly date mark potentially hazardous foods, risking foodborne illness.
Report Facts
Weight loss: 18.7
Missed medication doses: 4
Date of survey: Mar 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Named in medication self-administration assessment deficiency | |
| Director of Nursing | DON | Interviewed regarding medication self-administration and pain medication availability |
| RN H | Registered Nurse | Interviewed regarding sharps storage and resident feeding |
| CNA J | Certified Nursing Assistant | Interviewed regarding resident feeding and intake |
| Speech Therapist K | Interviewed regarding feeding evaluation for resident R32 | |
| Physician L | Medical Director/Attending Physician | Interviewed regarding resident R32 weight loss and failure to thrive |
| Social Work Director B | Social Work Director | Interviewed regarding delay in oral surgery referral |
| Director of Food Service N | DFS | Interviewed regarding food safety and kitchen sanitation deficiencies |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
The document is an administrative review and renewal of the Home for the Aged license for the facility The Legacy at Howell, confirming substantial compliance with public health code and administrative rules over the past year.
Findings
The review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license for 12 months effective 07/07/2023.
Report Facts
License duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Signed the renewal letter and communicated the licensing decision |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 28, 2023
Visit Reason
Routine inspection of The Willows at Howell nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident privacy with unauthorized video monitoring, delays in procuring appropriate wheelchairs, inconsistent pressure ulcer care, incomplete medication regimen reviews, medication administration errors, food safety violations, and inadequate resident understanding of binding arbitration agreements.
Deficiencies (7)
F 0550: The facility failed to safeguard resident privacy by allowing a resident's room to be audio and video recorded, including hallway areas, without proper consent or fixed camera positioning.
F 0684: The facility failed to procure an appropriate wheelchair in a timely manner for one resident, resulting in use of an ill-fitting wheelchair.
F 0686: The facility failed to consistently implement pressure ulcer interventions for one resident, risking new ulcers, worsening existing ulcers, and delayed healing.
F 0756: The facility failed to ensure monthly medication regimen reviews and physician responses for four residents, with missing documentation and follow-up.
F 0760: The facility failed to ensure entire doses of intravenous antibiotic medication were infused for one resident, risking untreated infection.
F 0812: The facility failed to discard expired food, maintain kitchen equipment cleanliness, and properly cool potentially hazardous foods, risking biological contamination.
F 0847: The facility failed to ensure six residents received clear understanding of the binding arbitration agreement prior to signing, including rights to refuse and litigation options.
Report Facts
Expired food items: 15
Temperature readings: 43.3
Temperature readings: 46.8
Temperature readings: 47.2
Medication doses remaining: 2
Pharmacist recommendation months missing: 3
Pharmacist recommendation months missing: 5
Pharmacist recommendation months missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Guest Relations Staff | Responsible for assisting residents with paperwork including binding arbitration agreement and explaining the process |
| Director of Nursing | Director of Nursing | Interviewed regarding video camera use and medication infusion process |
| Therapy Director D | Therapy Director | Interviewed about wheelchair evaluation and family interactions |
| Social Services H | Social Services | Interviewed about wheelchair ordering and family communications |
| Staff member B | Facility Staff | Interviewed about medication regimen review process |
| Staff member C | Wound Care Nurse | Interviewed about pressure ulcer assessment and follow-up |
| Dietary Manager G | Dietary Manager | Interviewed about food safety, expired food removal, and cooling procedures |
Inspection Report
Original Licensing
Capacity: 39
Deficiencies: 0
Date: Feb 17, 2021
Visit Reason
The facility requested to convert a former resident sitting area into a new private resident room, increasing the bed capacity from 38 to 39.
Findings
A video inspection on 2021-02-17 found the new room compliant with facility standards, including adequate square footage and amenities, and no issues were identified with the addition of the room. Fire safety and occupancy approvals were obtained prior to the inspection.
Report Facts
Bed capacity increase: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Conducted video inspection and authored report |
| Russell Misiak | Area Manager | Signed off on report |
Inspection Report
Original Licensing
Capacity: 38
Deficiencies: 0
Date: Jun 10, 2015
Visit Reason
The inspection was conducted as part of the original licensing process for The Willows at Howell, a newly constructed home for the aged facility seeking licensure to operate with a maximum capacity of 38 residents.
Findings
The facility was found to be in substantial compliance with applicable licensing statutes and administrative rules. The building and resident rooms met all regulatory requirements, and the fire safety inspection was approved. The facility was recommended for issuance of a temporary license for 38 residents.
Report Facts
Licensed capacity: 38
Staff shifts: 3
Square footage: 24000
Resident rooms: 33
Double occupancy rooms: 5
Scheduled move-ins: 28
Surety bond amount: 10000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emery Dumas | Administrator and Authorized Representative | Named as the administrator and authorized representative of The Willows at Howell. |
| Loma M Campbell | Licensing Staff | Author of the licensing study report. |
| Betsy Montgomery | Area Manager | Approved the licensing report. |
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