Villa at Willow Place: Chemo Gap for Cancer Patient - MI
The resident, identified in inspection records only as R200, was receiving capecitabine, a chemotherapy medication taken by mouth, through a PEG tube twice daily. The drug was part of a cycle his oncologist had prescribed: 14 days on, 7 days off, then repeat. At some point in July, the medication stopped. It did not resume for roughly 30 days.
Nobody filed a medication error report. The facility had none on record for this resident.
When inspectors visited on September 15, 2025, they asked the Director of Nursing and the Assistant Director of Nursing to walk them through what happened. The Director of Nursing explained the facility's standard process: when a resident goes to an outside appointment, the paperwork comes back with them, the receiving nurse reviews it for any medication changes, and adjustments are made from there. Clean, in theory.
What actually happened with R200 was something else. Inspectors asked why there was a 30-day window where the resident didn't receive his chemotherapy. The Director of Nursing said the resident had been hospitalized. The Assistant Director of Nursing then walked that back. After looking into it, both administrators acknowledged that no hospitalization had occurred during the period when the medication wasn't given.
The Assistant Director of Nursing offered a different explanation: the nurse practitioner who had written the order that ended in July had been terminated from the facility. Beyond that, no further explanation was provided.
That was it. A fired NP, and a month without chemotherapy, and nothing in between to connect one to the other.
Inspectors asked the facility to produce documentation from R200's oncologist that would support stopping the medication. The only records provided were dated August 21 and August 25, 2025, well after the gap had already occurred. No consult notes from before or during the period the medication was withheld were ever produced. Nothing in the record showed anyone had ordered the chemotherapy stopped. Nothing showed anyone had decided it should be paused. The medication simply wasn't given.
A progress note from a licensed practical nurse, dated August 4, 2025, documented that R200 had returned from an oncology appointment and was to continue his chemotherapy as directed, on the 14-day-on, 7-day-off schedule. The note suggests the oncologist expected the regimen to be ongoing. A separate notation flagged that when R200 had been taken to that appointment, no notes or orders from the facility had accompanied him. The oncologist examined him anyway, with no documented concerns, and added follow-up appointments for oncology and infusion.
The inspection was triggered by a complaint. It resulted in a citation under F0684, which covers the standard of care residents are entitled to receive. CMS categorized the harm level as minimal harm or potential for actual harm, affecting few residents.
Capecitabine is an oral chemotherapy agent used to treat certain cancers, including colorectal and breast cancer. It works by interfering with the growth of cancer cells and is typically given on a precise cycle because the timing of doses and rest periods is clinically significant. A 30-day interruption in a chemotherapy regimen is not a minor administrative oversight.
The facility's own nursing leadership, as of the day inspectors arrived, had not produced any documentation to account for the gap, had initially misremembered whether the resident had even been hospitalized, and ultimately pointed to the departure of a single staff member as the closest thing to an explanation.
R200's oncologist, as far as the inspection record shows, was never told the medication had stopped.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa At Willow Place from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
Villa at Willow Place in Ypslianti, MI was cited for violations during a health inspection on September 15, 2025.
The drug was part of a cycle his oncologist had prescribed: 14 days on, 7 days off, then repeat.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.