CCN 235700

The Willows At East Lansing

3500 Coolidge Road, East Lansing, MI 48823 · Clinton County

Phone: (517) 203-4042
Ownership: For profit - Corporation
Certified beds: 65
Residents per day: 61.8
Health citations: 30
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 5 · short-stay 4.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

CMS has marked this home with the high-performing icon. The September 2026 Technical Users' Guide describes that icon for homes with fewer citations, higher staffing, and other quality indicators, shown in addition to the five-star rating. Selection criteria are in CMS memorandum QSO-26-14-NH.

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.90; 2.33; 2.32
LPN/LVN: 0.31; 0.88; 0.86
Registered nurse: 1.65; 0.78; 0.69
Total nurse staff: 3.86; 3.99; 3.86
Weekend total: 3.25; 3.50; 3.42
Weekend RN: 1.33; 0.49; 0.48

Adjusted total nurse hours: 3.90. Adjusted RN hours: 1.67. Case-mix total: 3.80. Case-mix index: 1.389.

Total nursing staff turnover: 30.0%. RN turnover: 10.5%. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: January 8, 2026. Health deficiencies counted in cycle 1: 9. Cycle 1 total health score: 52.

Cycle 2 standard survey: October 17, 2024. Cycle 2/3 health deficiencies: 10. Total weighted health survey score: 51.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 30 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

March 20, 2026

2 citations

Tag	What CMS cited	Scope and severity	Status
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 31, 2026
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 31, 2026

January 8, 2026

7 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F585	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. Resident Rights Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F578	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F644	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F645	PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 28, 2026

October 17, 2024

8 citations

Tag	What CMS cited	Scope and severity	Status
F656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 13, 2024
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 11, 2024
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 13, 2024
F740	Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 11, 2024
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 11, 2024
F887	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. Infection Control Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 11, 2024
F623	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 11, 2024
F625	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. Resident Rights Deficiencies · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 11, 2024

July 5, 2024

2 citations

Tag	What CMS cited	Scope and severity	Status
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2024
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2024

September 20, 2023

11 citations

Tag	What CMS cited	Scope and severity	Status
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F585	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. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F644	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F645	PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F847	Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
CMS flags this provider as a continuing care retirement community.
Chain name in the file: Trilogy Health Services (127 facilities). Chain average overall rating: 4.2.
Legal business name: Trilogy Healthcare of Clinton LLC.
First approved for Medicare and Medicaid services: May 16, 2014.
Resident and family council: None.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for The Willows At East Lansing?

The Willows At East Lansing has an overall rating of 5 out of 5. The health inspection rating is 3, staffing is 5, and the quality measure rating is 5.

How many health citations does CMS list for The Willows At East Lansing?

The Health Deficiencies file lists 30 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for The Willows At East Lansing?

CMS reports 3.86 total nurse hours per resident per day, including 1.65 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

September 20, 2023

11 citations

Tag	What CMS cited	Scope and severity	Status
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F585	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. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F644	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F645	PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023
F847	Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 31, 2023