Ambassador, a Villa Center

Inspectors wroteThis citation pertains to intake 3018700. Based on interview and record review the facility failed to notify the resident representative for one resident (R502) of three reviewed for notification of changes.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Properly store food items; 2. Remove undated, unlabeled food from the kitchen walk-in cooler and the reach in freezer; 3. Adequately clean kitchen surfaces. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in an increased potential for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure protected health information for one resident (R28) of 30 residents reviewed for privacy, resulting in the potential for unauthorized disclosure and access.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide Influenza and Pneumococcal Immunizations for three residents (R9, R128 and R7) of five residents reviewed with compromised health conditions resulting in the potential for infection and a decrease in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Covid-19 vaccinations for three residents (R7, R9 and R128) of five residents reviewed for vaccination administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms and at least 100 square feet for single Resident bedrooms, affecting 32 Resident rooms (#'s 113, 115, 117, 119, 120, 121, 122, 123, 124, 125, 126, 127, 129, 130, 131, 132, 133, 135, 138, 213, 215, 217, 219, 221,223, 224, 225, 226,227, 228, 229 and 230).

Inspectors wroteThis citation pertains to intake MI00151504. Based on observation, interview and record review the facility failed to ensure an injury of unknown origin for one resident (R905) of four sampled residents reviewed for abuse was reported to the State Agency, resulting in the potential for further injury of unknown origin or abuse to go unreported and not investigated.

Inspectors wroteThis citation pertains to intake MI00151504 Based on observation, interview and record review the facility failed to ensure an injury of unknown origin was investigated for one (R905) of four sampled residents reviewed for abuse, resulting in the potential for abuse to occur.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP) were implemented during wound care for two residents (R911 and R912) out of two residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to post and plan alternate meals and All Time Available food choices, resulting in numerous complaints of dissatisfaction with meal choices and food. This deficient practice affected 159 of 170 residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the physical plant and steam table wells used in the kitchen, affecting 159 of the 170 residents who consume food from the kitchen, resulting in the potential for cross contamination, bacterial harbage and staff injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dignity for one resident (R110) of three residents reviewed for dignity, resulting in verbalized feelings of embarrassment and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) document was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one (R57) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure podiatry services and treatment were provided in a timely manner for one resident (R110) of one resident reviewed for foot care, resulting in the growth of long toenails, build-up of flaky skin on resident's feet, and delay in needed treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide medically related social services for one resident (R70) of two residents reviewed resulting in the delay of obtaining a legal guardian to initiate discharge planning in a timely manner and the resident expressing frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms affecting 38 Resident rooms (#'s113, 115, 117, 119, 120, 121, 122, 123, 124, 125, 126, 127, 129, 130, 131, 132, 133,135, 138, 213, 215, 217, 219, 221, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 234, 235, 236, and 238).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R40) of four residents reviewed for accidents and hazards, resulting in R40 falling with fractures during staff assisted shower and increased likelihood for accidents and/or injuries.

Inspectors wroteIn a confidential resident group interview on 8/16/23 at 11:29 AM, 10 of 10 residents reported the lunch and dinner meals was not palatable. Several residents stated that they feel that have to order out to get a decent meal. 10 of 10 residents reported that the portion sized of the meal is small, comparing the portion to kid sized meals. 9 of 10 residents reported that the pork is too tough to cut or chew. 10 of 10 residents reported that the food is not warm and have observed the staff leaving the meal cart doors open and conversating instead of passing trays. In an interview on 08/17/23 at 10:24 AM, Dietary Manager (DM) reported that the residents have had some food committee meetings to discuss food concerns but has cancelled the past few monthly meetings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the physical facility, maintain plumbing in good repair, and maintain equipment, resulting in the potential for contamination of the physical facility and food product, affecting all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident rooms in good repair, maintain clean ventilation, and maintain backflow protection, resulting in a non-homelike facility and potential for contamination of the domestic water supply, affecting all residents in the facility.

Inspectors wroteThis citation pertains to intake: MI00133207 Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 34 residents (including Resident #40 and 115) on the third floor, reviewed for physical environment. The facility also failed to maintain a clean comfortable home like environment in the dining room on the third floor that had the likelihood to impact all residents who were using the dining room for their meals and other activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bed hold policy was provided to three (Resident #27, #125, and #207) of three residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy.

Inspectors wroteAccording to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 91 (R91) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage due to a motor vehicle accident, diabetes, and bi-polar disorder. R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 08/15/23 at 2:40pm, R91 was observed resting in bed, upon approach R91 initiated a conversation using American Sign Language (ASL) this surveyor is knowledgeable of alphabet and some basic ASL commonly used words. R91 reported he had no hearing ability, and did not use a hearing aid, when queried how he communicated with staff he reported by writing and pointed to his tablet and using gestures. [...]

Inspectors wroteDuring observation of the 1 South medication care on 08/17/2023 at 11:22 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of th medication: Fluticasone Propionate/Salmeterol discus 500 micrograms (mcg)/50 mcg and Lansoprazole 3 milligrams (mg)/milliliter (ml). In an interview on 08/17/2023 at 11;22 a.m. during 1 South medication care observation, Licensed Practical Nurse (LPN) T explained that all medication is to be dated when opened. She explained that she would discard the medication that was not dated, as listed above, and order new medication. During observation of the 2 South back medication cart on 08/17/2023 at 11:48 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of the medication: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) adhere to infection control practices during medication administration observation; and 2) maintain clean and sanitized environment including resident equipment and common areas, resulting in the potential for cross-contamination, spread of bacteria, and increased risk of infection.

Inspectors wroteThis citation pertains to intake #MI00133896. Based on observation, interview, and record review, the facility failed to ensure resident dignity for 2 residents (R#'s, 114 and 115) with a facility census of 154, resulting in the potential for embarrassment and decreased feelings of self worth.

Inspectors wroteThis citation pertains to intake: MI00133473 Based on record review and interview the facility failed to provide written or spoken notice of a room change for one resident (#359) of one resident reviewed for room change, resulting in the potential for resident anxiety, misinformation of the reason for the room move, and lack of opportunity for resident questions. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility facility to ensure one out of two residents (Resident #5) had an accurate Advanced Directive form, resulting in the potential for resident wishes to not be followed. Findings Included: Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. On the signature line for Resident/Responsible Party the form revealed Verbal Consent dated 12/9/2022, but there was no name of the person who gave verbal consent. [...]

Inspectors wroteThis citation pertains to Intake: MI00138470 Based on interview and record review the facility failed to notify the family member/emergency contact of a change in condition and a required hospital transfer for one resident (#356) of two residents reviewed resulting in the family/emergency contact not being aware of a change in condition and the transfer to the hospital. Findings Included: Resident #356 (R356) Review of the medical record revealed R356 was admitted to the facility 02/10/2023 with diagnoses that included fracture of the left femur, type 2 diabetes, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat in blood), cerebral infarction (stroke), muscle weakness, hearing loss, and dysphagia (difficulty swallowing). [...]

Inspectors wroteThis citation pertains to Intakes: MI00137118 and MI00135021 Based on interview and record review the facility failed to protect two residents (#357, #358) right to be free from abuse of five residents reviewed resulting in the potential of physical harm to the residents. Findings Included: Resident #357 (R357) Review of the medical record revealed R357 was admitted to the facility 11/11/2021 with diagnoses that included right hip osteoarthritis, left sided hemiplegia (paralysis), hyperlipidemia (high fat in blood), dissociative and conversion disorder (mental health condition causes a person to become disconnected form important aspects of their lives and can mimic neurological conditions), nutritional deficiency, muscle weakness, psychomotor deficit (disturbance in psychological control of movement), and hypertension. [...]

Inspectors wroteThis citation pertains to intake: MI00135021 Based on interview and record review the facility failed to report allegations of abuse (physical abuse) for two residents (#358, #360) of five residents sampled resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #358 (R358) Review of the medical record revealed R358 was admitted to the facility 01/31/2023 with diagnoses that included malignant neoplasm (cancer) of the prostate, obstructive and reflux uropathy (disorder of the urinary tract), hyperlipemia (high fat in blood), protein calorie malnutrition, hypokalemia (low potassium) hypomagnesemia (low magnesium), altered mental status, dementia with behavioral disturbance, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to a hospital for one (Resident #125) of three residents reviewed for transfer/discharge, resulting in the potential of residents and/or family being un-informed of the reason for transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #91) of 31 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Residents ( #107) and failed complete the 3878 portion of the PAS/ARR for 1 Resident (60) of 4 residents reviewed for PAS/ARR from a total sample of 31, resulting in the potential for unmet mental health treatment and services.

Inspectors wroteThis citation pertains to intake: MI00136732 Based on interview and record review, the facility failed to provide bath/showers and continence care for one Resident (#208) of 5 Residents reviewed, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Resident #208 (R208) Review of the medical record revealed R208 was admitted to the facility 05/03/2023 with diagnoses that included hyperlipidemia (high fat in blood), congestive heart failure (CHF), major depression, hypothyroidism (low thyroid hormone), hypertension, morbid obesity, fractur of right femur, atrial fibrillation, gastroesophageal reflux, anemia (low red blood cells), osteoarthritis, and muscle weakness. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance to ensure ancillary services were arranged for 2 of 4 residents (Residents #141 and 3) reviewed for optical care, and audiology care, resulting in delayed care and treatment and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy and procedures to assure the accurate dispensing, administering, and documentation of controlled substances for two of five medication carts, resulting in the potential for controlled drug diversion. Findings Included: During observation of the 1 South medication cart on 08/17/2023 at 11:22 a.m. it was observed that the document entitled Controlled Substance Shift Inventory was not signed for 08/17/2023 at 07:00 a.m. by the oncoming nurse. The total number of medications at the end of the shift was also not completed. In an interview on 08/17/2023 at 11:25 a.m. Licensed Practical Nurse (LPN) T explained that she was the oncoming nursing for the 1 South medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 2 medication errors were observed from a total of 36 opportunities for one resident (R121) of four residents observed during medication administration, resulting in a medication error rate of 5.56 percent (%).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services for one of three residents reviewed for dental services (Resident #139), resulting in continued mouth pain and unmet needs. Findings Include: Resident #139 (R139) R139 was observed sitting on her bed on 8/15/23 at 1:00 PM and stated during an interview that she had oral pain, had cavities, and needed a crown. In review of R139's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she was admitted to the facility on [DATE]; had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 Cognitively Intact); and required extensive assistance for personal hygiene (includes brushing teeth). The same MDS assessment indicated R139 had obvious or likely cavity or broken natural teeth. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two out of 31 one resident's (Resident #5 and 75) medical records were complete and accurate resulting in the potential for unmet care needs. Findings Included: Resident #5 (R5): Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. [...]