The Villa at City Center

Inspectors wroteThis citation pertains to Intake 3024714. Based on interview and record review, the facility failed to ensure the resident's medications were available to administer per physician's orders for one resident (R901) of one reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to timely submit a MDS (Minimum Data Set) assessment for five residents (R8, R30, R39, R88, R97) of nine residents reviewed for resident assessment. Findings Include:R8A record review revealed the MDS discharge assessment was 120 days overdue. Further review of the medical record noted R8 was admitted to the facility on [DATE]. R8 was discharged on 10/26/25. A review of the Minimum Data Set (MDS) assessment did not reveal a discharge MDS having been submitted. R30A record review revealed R30 was admitted to the facility on [DATE]. R30 was discharged on 12/7/25. A discharge MDS was not submitted. R39A record review revealed R39 was admitted to the facility on [DATE]. R39 was discharged on 12/7/25. A MDS was not submitted. R88A record review revealed R88 was admitted to the facility on [DATE]. R88 was discharged on 12/13/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one (R5) of six residents reviewed for baseline care plans.

Inspectors wroteBased on observation, interview and record review the facility failed to implement post fall interventions for one resident (R145) of three whose falls were reviewed.

Inspectors wroteBased on interview and record review, the facility failed to follow through on physician recommendations following a change in condition for one (R5) of three residents reviewed for laboratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for four residents (R32, R44, R65, R146), three anonymous residents, and three anonymous resident council group residents from a census of 137.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at a preferred and palatable temperature for one resident (R80) and four of eight confidential group residents reviewed for food palatability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete assessments to determine need for bed rails for one resident (R24) of one residents reviewed for bed rails. On 1/06/25 at 9:12 AM, R24 was observed lying in bed watching television with bilateral bed rails up on each side of the bed. On 1/07/25 at 11:07 AM, R24 was observed laying in bed with the bilateral bed rails up on each side of the bed. R24 was asked why there were rails on the bed and R24 shrugged shoulders and stated they keep me safe. A review of R24 medical record revealed R24 was admitted on [DATE] with multiple diagnosies including muscle weakness, type II diabetes mellitus with diabetic peripheral angiopathy with gangrene, and artherosclerosis of native arteries of extremities with gangrene right leg. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications and supplies were discarded when expired in two of two medication carts and one of one medication storage room.

Inspectors wroteThis citation pertains to Intake MI00146289. Based on interview and record review, the facility failed to ensure the resident's responsible party was informed of skin changes for one resident (R901) of three residents reviewed for skin management.

Inspectors wroteThis citation pertains to Intake MI00146289. Based on observation, interview, and record review, the facility failed reposition a dependent resident while in bed for one resident (R902) of three reviewed for skin management resulting in the re-opening of a sacral wound.

Inspectors wroteThis citation pertains to Intake MI00141837. Based on interview and record review, the facility failed to hold a medication per physician order for one resident (R700) out of one reviewed for physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteR31 A review of R31's progress notes, revealed Medication Regimen Reviews (MMR's) dated 8/17/23, 9/19/23 see report. A review of R31's medical record revealed, R31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral infraction. A review of R31's Minimum Data Set (MDS) assessment dated [DATE] noted, R31 with an impaired cognition and required extensive assistance from one staff person for activities of daily living (ADLs). A review of the two pharmacist's recommendations dated, 8/17/23 and 9/19/23 both revealed the following: [R31] has an order for lisinopril 10 mg (milligram) daily and has had either high normal or above high normal serum potassium levels in the past several months. Please consider if lisinopril can be withheld or discontinued and will continue to monitor serum potassium. [...]

Inspectors wroteThis citation pertains to Intakes MI00138808 and M100139419. Based on observation, interview and record review, the facility failed to ensure that one (R8) of seven residents reviewed was treated with dignity, resulting in the resident experiencing feelings of depression and hopelessness regarding their potential for improved independence and increased socialization. Findings Include: Review of the facility record for R8 revealed an admission date of 02/28/23 with diagnoses that included Multiple Sclerosis, Paraplegia, Major Depressive Disorder and Stage IV (full thickness skin and tissue loss with exposed dermis, adipose (fat) tissue and various underlying structures) Sacral Pressure Ulcer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R8 required primarily Total/Maximum level assistance for transfers, mobility and bathing/dressing. [...]

Inspectors wroteThis citation pertains to Intake MI00138776. Based on interview and record review, the facility failed to conduct quarterly care conferences for one resident (R67) out of one reviewed for care planning, resulting in the guardian not being involved in the plan of care. Findings Include: A review of Intake MI00138776 revealed the following, As [R67] legal guardian and [family member], I am the first point of contact, and I was not notified of any health concerns [R67] was having . A review of the medical record revealed that R67 readmitted into the facility on 1/7/2023 with the following diagnoses, Dysphagia and Alzheimer's Disease. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating that R67 was unable to complete the assessment. [...]

Inspectors wroteThis citation pertains to Intake: MI00140274. Based on interview and record review, the facility failed to operationalize policies and procedures by notifying the resident's representative and physician of a fall in a timely manner for one resident (R387) of one reviewed for notification resulting in, the resident's representative and physician being unaware, and the inability to participate and make medical decisions regarding care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to readmit or document reason for readmission to the facility following a hospitalization, for one sampled resident (R187) of three residents reviewed for hospitalization, resulting in dissatisfaction in care and a transfer to another facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned interventions for two residents (R11 and R9) out of four reviewed for care plans, resulting in the increased potential for accidents, hazards and unmet care needs. Findings Include: R11 On 10/24/2023 at 9:00 AM, R11 was observed eating breakfast. R11's ticket noted that they were supposed to have a disposable set-up. R11 was observed with a regular plate and silverware. On 10/24/2023 at 12:29 PM, R11 was observed eating lunch with a regular plate and silverware. A review of the medical record revealed that R11 admitted into the facility on 1/4/2022 with the following diagnoses, Cerebral Infarction and Dysphagia. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 6/15 indicating impaired cognition. [...]

Inspectors wroteThis citation pertains to Intakes MI00138808 and MI00140274. This citation has two deficient practice statements. Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for two resident (R11 and 81) out of three reviewed for meal assistance, resulting in the potential for aspiration and inadequate food intake. Findings Include: R11 On 10/24/2023 at 9:00 AM, R11 was observed eating breakfast. R11's meal ticket noted 1:1 assistance in red and bolded. R11 was observed sitting up, eating breakfast without staff assistance. On 10/24/2023 at 12:29 PM, R11 was observed eating lunch without staff assistance. A review of the medical record revealed that R11 admitted into the facility on 1/4/2022 with the following diagnoses, Cerebral Infarction and Dysphagia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities for one resident (R31) of two resident reviewed for activities, resulting in a lack of meaningful activities and increased symptoms of depression.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure splints/braces were applied for one resident (R31) of two residents reviewed for positioning/mobility resulting in the potential for decreased range of motion (ROM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services, for one resident (R31) of three reviewed for dental care, resulting in the potential for further oral health decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food in a palatable manner and at the preferred temperature for two residents (R46 and R81) and seven confidential group residents of fifteen residents reviewed for food palatability, resulting in dissatisfaction during meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain tube feeding pole and a nebulizer mask in a sanitary manner, for one resident (R70) of one, resulting in the potential for contamination of equipment and cross contamination.