The Villa at Great Lakes Crossing

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing the required personal protective equipment (PPE) during wound care for three residents (R401, R402 and R403) of three residents reviewed under EBP due to colonization or risk factors associated with multidrug-resistant organisms (MDROs). The failure to utilize required isolation gowns during high-contact resident care increased the risk of transmission of MDROs and other infectious pathogens among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure wall surfaces were in good repair and cleanable; 2. Ensure light fixtures, vents, and a resident refrigerator were maintained in a clean and sanitary manner; 3. Ensure cleaned ladles were properly stored; and 4. Properly date-label food in the resident refrigerators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the reach-in cooler, located in the dietary office, was maintained in good working order.

Inspectors wroteBased on interview and record review the facility failed to complete and/or ensure the timely completion of comprehensive resident assessments (a complete interdisciplinary evaluation of a resident's physical , mental, psychosocial and functional status) in accordance with regulatory requirements for 13 residents (R4, R6, R33, R53, R72, R93, R94, R95, R101, R114, R124, R125, and R139) out of 13 residents reviewed for Minimum Data Set (MDS) assessment accuracy and timeliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare meat and vegetables to the proper food consistency for the 23 residents receiving mechanical soft textured meals and 4 residents receiving pureed textured meals in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide scheduled showers for one resident (R37) and timely nail care for one resident (R18) out of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were properly stored in accordance with accepted standards in one of three medications refrigerators reviewed. This deficient practice had the potential to affect the safety and integrity of medications stored for resident use.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of five Certified Nurse Aides (CNA O, P, and Q) completed the required 12 hours of annual training to ensure adequate resident care.

Inspectors wroteBased on interview and record review the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness needs in a timely manner for three (R13, R15, and R56) of five residents reviewed for PASAAR, resulting in the potential for residents not to receive care and services appropriate to their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, implement, and revise care plans for one resident (R83) of two residents reviewed with an indwelling catheter, resulting in the potential for a lack of monitoring, implementation of interventions and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate and safe storage of an oxygen tank at the bedside of one Resident 54 (R54) of three residents reviewed for respiratory care, resulting in the potential for environmental hazard and resident injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident R16 of four residents reviewed for catheter care with the potential to cause irritation and/or trauma.

Inspectors wroteBased on observation, interview, and record review the facility failed to date respiratory equipment for two residents (F9 and F16) of three residents reviewed for respiratory care.

Inspectors wroteThis citation pertains to intake #MI00148730 Based on observation, interview, and record review, the facility failed to ensure the use of an appropriate wheelchair for one resident (R902) of three residents reviewed for accidents, resulting in a fractured tibia and fibula (the two long bones in the lower leg that connect the knee to the ankle).

Inspectors wroteThis citation pertains to intake #MI00148730. Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one resident (R903) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #MI00147795 Based on observation, interview, and record review, the facility failed to appropriately assess and treat pain for one resident (R903) of three residents reviewed for pain.

Inspectors wroteThis citation pertains to intake MI00146222. Based on interview and record review the facility failed to inform the Physician of an abnormal x-ray result in a timely manner for one resident (R901) out three residents reviewed for notification of change, resulting in a delay in further treatment.

Inspectors wroteThis citation pertains to MI00144894. Based on observation, interview, and record review the facility failed to administer tube feeding per physician order for one (R604) of three resident's reviewed for tube feeding, resulting in the potential for nutrition needs not being met and un-intended weight loss.

Inspectors wroteBased on interview and record review, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner, for nine (R3, R6, R8, R18, R19, R39, R43, R47, and R73) of 11 residents reviewed for resident assessments, resulting in the delay of time-sensitive information, potentially affecting the level of care and quality of life for the identified residents.

Inspectors wroteBased on interview and record review, the facility failed to notify one resident (R88) of three residents reviewed for Beneficiary Protection Notice about the discontinuation of their Medicare part A skilled benefits in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to complete a change in condition PASARR (Pre-admission Screening and Annual Resident Review) Level One Form for one resident (R61) of four residents reviewed for PASSARs, resulting in the PASARR Level Two screening not being completed and potential lack of mental health care services. Findings Include: A review of R61's EMR (Electronic Medical Record) revealed, R61 was admitted to the facility on [DATE]. R61 had a medical diagnosis of Major Depressive Disorder. A review of R61's Quarterly MDS (Minimum Data Set) dated 1/2/24 revealed R61 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). [...]

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive skin condition care plan for one resident (R27) of one resident reviewed for skin conditions.

Inspectors wroteBased on Observation, interview, and record review the facility failed to date oxygen tubing for one resident (R61) of three residents reviewed for oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform proper hand hygiene and glove usage during catheter care for one resident (R39) of one resident reviewed for urinary catheters resulting in the potential for the spread of infection.

Inspectors wroteThis citation pertains to intake MI00141391. Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency (prior to investigation) for one resident (R902) out of three residents reviewed for accidents, resulting in the facility not reporting an injury of unknown origin to the State Agency and the potential for continued unreporting of incidents of unknown injury.

Inspectors wroteThis citation pertains to intake MI00141391. Based on interview and record review the facility failed to reposition a total dependent resident (R902) out of three residents reviewed for accidents, resulting in a head injury.