Father Murray, a Villa Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, homelike environment affecting two residents (R73 and R17) of three reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to notify or provide one resident (R194) or their representative of a bed hold (a policy on how a resident's bed will be held or reserved while they are absent from the facility) upon transfer to the hospital out of two residents reviewed for hospital discharges.

Inspectors wroteBased interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments timely for two residents (R18 and R215) of 12 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned interventions for one resident (R39) of three reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan intervention for one resident (R24) out of three reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply soft lift heel boots for one resident (R9) out of one reviewed for physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow provide oversight during medication administration for one resident (R904) of one reviewed for professional standards of practice.

Inspectors wroteThis citation pertains to Intake number 2809219. Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by facility staff for one (R900) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake 2699034Based on observation, interview, and record review, the facility failed to protect one resident (R904) from sexual abuse from another resident (R903) out of five reviewed for abuse.

Inspectors wroteThis citation pertains to Intake 2609700. Based on observation, interview, and record review, the facility failed to schedule a follow up consultation appointment for one resident (R903) out one reviewed for appointments.

Inspectors wroteThis citation pertains to 2598400 and 2609700. Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment in one of one bathroom on the 100 unit, and in two of four shower rooms.

Inspectors wroteThis citation pertains to Intake: 2567551Based on observation, interview, and record review, the facility failed to honor one resident's self-determination rights (R701) of one reviewed for resident rights.

Inspectors wroteThis citation pertains to Intake MI00153991. Based on interview and record review, the facility failed to document and inform resident representative about changes in skin integrity for one sampled resident (R901) of three residents reviewed for informed rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for one (R121) of eight residents reviewed for homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to submit a Minimum Data Set Assessment (MDS-a form to be completed for all residents Medicare/Medicaid information) in a timely manner for one (R157) of one residents reviewed for assessments.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for three residents (R3, R8, R13) of eight residents reviewed for PASARR (Preadmission Screen and Resident Review).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure mouth care was provided for one resident (R137) of four dependent residents reviewed for oral hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for one resident (R5) of one resident and failed to store/date medication in one of two medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store oxygen mask and tubing in a sanitary manner for one (R98) of four residents reviewed for supplemental oxygen use.

Inspectors wroteBased on interview and record review, the facility failed to immunize per acceptable and/or declination for influenza immunizations for one resident (R81) of five sampled residents reviewed for immunizations. Findings Include: A review of R81's medical record revealed they were admitted into the facility on 2/1/24. During a review Infection Control program, the influenza acceptance/declination for R81 was requested and revealed a consent to receive the influenza immunization dated for 10/4/24. Reviewed was a second document dated for 10/10/24 declining the influenza vaccine. A review of the resident's medical record revealed the resident received the influenza immunization on 10/14/24 (four days after declining it). [...]

Inspectors wroteBased on interview and record review, the facility failed to document the education regarding benefits and offering of immunizations (COVID vaccine), and immunize per acceptable and/or declination for three residents (R7, R13, and R63) of five sampled residents reviewed for immunizations. Findings Include: During a review of the Infection Control program, acceptance/declinations of the COVID vaccine were requested for R7, R13, and R63. R7 A review of R7's medical record revealed they were admitted into the facility on 7/16/16. A review of R7's COVID declination was signed by the resident during the survey on 4/8/25 however, the resident has a guardian responsible for making medical decisions on their behalf. R13 A review of R13's medical record revealed they were admitted into the facility on [DATE]. [...]

Inspectors wroteThis citation is related to Intake MI100147010. Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment in one bathroom for two (R907) of two residents assigned to the same room.

Inspectors wroteThis citation pertains to MI00145143, MI00145149, and MI00145155. Based on interview, and record review the facility failed to ensure timely follow up by social work and psychiatric services and physician notification for suicidal ideations for one (903) of one residents reviewed for mental health disorders.

Inspectors wroteThis citation pertains to intake MI00144520. Based on observation, interview, and record review, the facility failed to protect one resident's (R703) right to be free from physical abuse by another resident (R704), of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake MI00144520. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (R703) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake Number MI00142477 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff, affecting one resident (Resident #135) of five residents reviewed for abuse, resulting in R135 experiencing physical and psychosocial harm as determined by the reasonable person concept.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure full visual privacy during the care of two residents (R43 and R87), resulting in the exposure of sensitive parts of the residents' bodies to other residents and the potential for embarrassment.

Inspectors wroteThis citation pertains in part to Intake Numbers MI00140365 and MI00141049. Based on observation, interview, and record review, the facility failed to provide a clean and kempt environment affecting one resident (Resident 144) of six residents reviewed for environment, and three resident bathrooms.

Inspectors wroteBased on interview and record review the facility failed to notify the Ombudsman of hospital transfer for one resident, (R201) of one resident reviewed for discharge/transfer.

Inspectors wroteBased on interview and record review, the facility failed to complete PASARR II (Preadmission Screening and Resident Review II) in a timely manner for two (R73 and R101) of three residents reviewed.

Inspectors wroteThis citation pertains to Intake Number MI00140365. Based on observation, interview and record review the facility failed to ensure that a resident was repositioned timely and appropriately for one resident (R87) of three residents reviewed with wound care needs, resulting in the increased potential for delayed wound healing and wound deterioration.

Inspectors wroteThis citation pertains to Intake Numbers: MI00140260, MI00140264, and MI00142715. Based on observation, interview, and record review, the facility failed to provide timely incontinence care for one resident (R175) out of 11 residents reviewed for Activities of Daily Living (ADL). Findings Include: Resident #175 (R175): On 2/28/24 at 8:57 AM, R175 reported that they have to wait a long time to have their brief changed. R175 stated, It's worse on midnights. R175 explained, that one time they pressed the call light at 1:00 am and didn't get help until almost 9:00 am. R175 further explained, that they have impaired skin on their backside and that a wet brief makes their skin burn. On 2/28/24 at 1:16 PM, R175 was observed lying in bed. The bed sheet was observed to have a large wet circle around R175. The wet circle reached the middle of R175 back to the lower part of R175's legs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate wound care interventions for one resident (R352) of four residents reviewed for skin management.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to prevent a fall for one resident (R109) of four residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the care plan included interventions for one resident (R21) with a diagnosis of Post Traumatic Stress Disorder (PTSD), resulting in the potential for staff to trigger episodes of aggression, re-traumatization and unmet care needs.

Inspectors wroteBased on observation, observation and interview the facility failed to ensure that medications were properly tabled and stored in one medication cup and three residents' rooms (R119, R191, and R603) resulting in the potential for diversion of the medication and or misuse.

Inspectors wroteThis citation pertains to Intake Number MI00140264. Based on observation, interview, and record review the facility failed to honor food preferences for one resident (R160) of two residents reviewed for food preferences resulting in resident verbalized frustration.