Cycle 1
Health 2024-10-17 · Fire 2024-10-17
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
East Lansing, MI
The Willows At East Lansing
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3500 Coolidge Road, East Lansing, MI
(517) 203-4042
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-05-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.34
Registered nurse staffing
LPN hours / resident day
0.45
Licensed practical nurse staffing
Aide hours / resident day
1.97
Nurse aide staffing
Weekend hours
3.17
Weekend nurse staffing
RN turnover
22%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
95.0%
1.3 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.1%
2.4 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.1%
3.3 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.5%
0.9 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
19.6%
5.4 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
16.5%
3.8 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.8% |
13.9%
7.1 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
11.7%
5.5 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
20.4%
2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.6%
3.3 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
82.8%
13 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
11.5%
1.4 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
79.5%
16.3 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
24.2%
9.1 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-07 · Fire 2022-10-07
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-11
E · Potential for more than minimal harm
2023-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-31
E · Potential for more than minimal harm
2022-10-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-17
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-11-11
B · Minimal harm
2024-10-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-11
B · Minimal harm
2024-10-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-07-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-22
D · Potential for more than minimal harm
2023-09-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-04-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-20
E · Potential for more than minimal harm
2022-10-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-02
E · Potential for more than minimal harm
2022-10-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-02
C · Minimal harm
2022-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-02
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Ermiger, Joseph
Operational/Managerial Control · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Prosky, Danny
Corporate Officer · Individual
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Medilodge of East Lansing
East Lansing, MI
1-star overall rating with 1-star inspections with $39,462 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Burcham Hills Retirement Center
East Lansing, MI
1-star overall rating with 1-star inspections with $37,557 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Medilodge of Campus Area
East Lansing, MI
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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