Villa At Willow Place
Villa at Willow Place in Ypslianti, MI — inspection on September 15, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
notes from oncology as no noted orders or papers came with pt to appointment. Pt was examined at appointment with no concerns.Follow up appointments with oncology an infusion were added to orders. Pt to continue with capecitabine tablet per peg tube twice daily per orders.Review of progress note from Licensed Practicing Nurse, LPN D, dated 8/4/25 documented in part Resident back from his appointment and continue with his chemo medicine as per NP from hospital- 14 days on and 7 days off and repeat the cycle and continue. On 9/15/25 at 2:44 PM, a request was made for any medication error reports for R200 and 2:51PM ADON reported they did not have any medication error reports for R200.
The facility was asked to provide any documentation from R200's oncologist.
The only notes that were provided were dated 8/21/25 and 8/25/25. No consult notes prior to the timeframe that R200 did not receive his oral chemotherapy medication were provided. No documentation found to support the medication should have been stopped. On 9/15/25 at 3:17 PM, during an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON), when asked what the facilities process is to review for any medication changes when a resident goes to an outside appointment, DON reported that paper work (consult report) is sent back to the facility with the resident or whomever accompanied the resident to the appointment. It is the responsibility of the receiving nurse to review for any medication changes.
When asked why there was a 30-day period where the resident did not receive his oral chemotherapy medication, DON reported that the resident had went out to the hospital. It was determined by ADON and DON that a hospitalization did not occur around the time the medication was not given. ADON reported that the NP that had written the order that ended in July had been terminated from the facility and no further explanation of why the medication was stopped was provided.
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