The Villa at the Bay

Inspectors wroteThis citation pertains to intake 3008577. Based on interview and record review, the facility failed to ensure staff competencies were performed for 5 staff members reviewed.

Inspectors wroteThis citation pertains to intake #2991669. Based on observation, interview, and record review, the facility failed to follow menus prepared in advance for six Residents (#41, 47, 48, 49, 50 & 51) of six residents prescribed a pureed diet.

Inspectors wroteThis citation pertains to intake #2991669. Based on interview and record review the facility failed to provide timely pharmaceutical services, for one Resident (#40) of three sampled residents reviewed for pharmacy services.

Inspectors wroteThis deficiency pertains to intake #2644019Based on interview and record review, the facility failed to prevent the involuntary seclusion of one Resident (#1) of three residents reviewed for involuntary seclusion. This deficient practice resulted in feelings of frustration and the potential for feelings of isolation, depression, psychological and emotional distress, and impaired mental health.

Inspectors wroteIntake: MI00150656This citation has two separate deficiencies. Based on interview and record review, the facility failed to provide all necessary care and services for one resident (R128) of one resident reviewed for quality of life, resulting in R128 not maintaining his highest practicable well-being, being hospitalized three times and endangering his life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to readily identify, promote healing, and prevent the development of pressure injuries for two Residents (#26 & R42) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R26 developing a stage 3 pressure ulcer that worsened into a stage 4 pressure ulcer, and R42 developing infection and the deterioration of pressure wounds.

Inspectors wroteBased on interview and record review, the facility failed to adhere to the applicable components of the process for transferring or discharging residents including the notice of bed-hold policy and the written notice of transfer or discharge to both the resident, resident's representative, and the representative of the Office of the State Long-Term Care (LTC) Ombudsman, with the reason for a transfer for five Residents (#1, #42, #50, #54, and #75) of five residents reviewed for transfers out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in accordance with the posted menu.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide meals in a timely manner and/or consistently provide a nourishing snack to all 82 residents. This deficient practice resulted in the potential for residents to not have a hot meal or to have more than 16 hours between a substantial evening meal and breakfast the following day, decreased oral intake, and the potential for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by: - storage of expired foods, - food preparation equipment not cleaned properly after use, - utensils and pans not properly cleaned and stored, - sanitizing solution not properly prepared, and - unit nourishment room had storage of outdated beverages and resident foods. This deficient practice has the potential to result in food borne illness among any and all 82 residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain an operable emergency electrical power system to ensure electrical power to life support systems in the event of a power outage, effecting all 82 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to utilize their emergency plan to allow residents to directly communicate and alert staff members of their needs during a power outage and generator failure affecting all residents residing at the facility. This deficient practice resulted in resident helplessness and potential decreased emergent response times.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate advanced directive information for four Residents (#17, #57, #62, #278) of four residents reviewed for advance directives (legal document that allows a person or their representative to identify medical care preferences if they should be unable to do so).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide scheduled showers for two sampled Residents (#18, #73) and three Confidential Residents (CR#6, #9, and #14) of 18 Residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete assessments to ensure safe self-administration of medication for three Residents (R60, R61, and R230) of 18 residents reviewed for right to self-administer medications.

Inspectors wroteBased on interview and record review the facility failed to follow their grievance procedure and make prompt efforts to resolve grievances regarding complaints of missing items for three Residents (#5, #11 and #22) of three residents reviewed for inaction of grievances.

Inspectors wroteBased on interview, and record review, the facility failed to revise and update care plans to reflect resident status for one Resident (#54) of 18 Residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services were provided to increase range of motion and/or to prevent further decrease in range of motion (ROM) for one Resident (#54) of one resident reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control measures pertaining to indwelling catheters (a tube inserted into the bladder to accommodate emptying of the bladder) for one Resident (#8) of two residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary storage, labeling, and cleaning of respiratory equipment for three Residents (#23, #42, and #61) of 3 residents reviewed for respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly perform hand washing and hand hygiene during wound dressing changes.

Inspectors wroteThis citation pertains to intake numbers; MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure 1. New admission orders were double checked, 2. Appropriate assessments and wound care were provided, and 3. Timely notification of a change in condition were completed per professional standards for one Resident (#3) of three residents reviewed for new admissions, resulting in R3 being transferred to the emergency department with post-surgical infection, respiratory distress, low blood pressure, sepsis, and subsequent death.

Inspectors wroteThis citation pertains to intake numbers: MI00150212 and MI00150297. Based on interview and record review, the facility failed to notify the residents emergency contact and attending physician of a change in condition for one Resident (#3) of three residents reviewed for notifications.

Inspectors wroteThis citation pertains to intake numbers: MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure sufficient staff to provide for resident's care needs, for one Resident (#3) of three residents reviewed for staffing.

Inspectors wroteThis citation pertains to intake numbers: MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure competent staff to provide for resident's care needs, for one Resident (#3) of three residents reviewed for staffing.

Inspectors wroteBased on interview and record review, the facility failed to administer physician ordered antibiotic medication for one Resident (#3) of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two Residents (R9, R18) of four residents reviewed for pressure ulcers. This deficient practice resulted in the development of one unstageable pressure ulcer and the potential for development of new/additional pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 77 residents.

Inspectors wroteBased on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 77 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, functional, and sanitary environment, potentially exposing all 77 residents to unsafe and unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine and honor food preferences for five residents (R6, R5, R17, R20, R27) and additional residents in a confidential group meeting. This deficient practice resulted in resident complaints of their food choices being ignored, extended wait times for alternate food choices, decreased meal enjoyment, and the potential for weight loss and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an injury due to smoking for one resident (R21) of two residents reviewed for smoking. This deficient practice resulted in R21 receiving two burns due to unsafe smoking habits.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure monitoring of weight and following of physician orders in providing proper diets to prevent weight loss for two Residents (#66 and #67) of two residents reviewed for significant weight loss, resulting in potential for delayed treatment, continued weight loss and decline in function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for two residents (Resident #14 and #37) of two residents reviewed for therapeutic diet orders. This deficient practice resulted in the delivery of fluid of inappropriate consistency resulting in the potential for decreased fluid intake, aspiration (accidental inhalation of food/fluid into the lungs), and associated respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to correctly identify, label and use personal protective equipment (PPE) for Enhanced Barrier Precaution (EBP) rooms per standards of practice for infection control measures according to the Centers for Disease Control and Prevention's (CDC) guidelines. This deficient practice resulted in the potential transmission of infectious agents to all 77 vulnerable residents in the facility.

Inspectors wroteThis citation pertains to Intake #MI00143565 Based on interview and record review, the facility failed to ensure resolution of resident grievances for Four Residents (R4, R5, R6, and R7) of six residents reviewed for grievance resolution.

Inspectors wroteThis citation pertains to Intakes #MI00143557, #MI00143565, #MI00143601 Based on observation, interview, and record review, the facility failed to provide sufficient numbers of Certified Nursing Assistants (CNAs) to provide necessary care and services for four Residents (R4, R5, R6, and R7) of six residents reviewed for sufficient staffing. This deficient practice had the potential for unmet care needs and the provision of inadequate care for all 69 residents in the facility.

Inspectors wroteThis citation pertains to Intakes #MI00144121 and MI00144264 Based on interview and record review, the facility failed to develop a care plan and implement interventions to reduce hazards and risks to prevent falls for one Resident (R1) of two residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respectful and dignified treatment for one Resident (R3) of three residents reviewed for resident rights. This deficient practice resulted in feelings of being disrespected and staff being rude.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure potentially hazardous foods (tortellini) were stored at proper temperature while waiting to be served. 2. Failing to demonstrate the proper cooling of potentially hazardous foods which were destined to be served at a later date. 3. Failing to ensure staff washed their hands after touching their head and hair 4. Failing to ensure staff were wearing proper hair restraint devices when present in food service and clean dish washing areas. These deficient practices have the potential to result in food borne illness among any and all 76 residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they were using the updated Michigan DNR Act verbiage, accurate advanced directive information and missing signatures was in place for five residents (#13, 30, 50, 56 and 65) of five residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), from a total sample of 18 residents, resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise resident care plans in 6 of 18 reviewed for care plans (Resident #19, #22, #27, #32, #38, & #46), resulting in the potential for unmet needs and services.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the environment was maintained in a safe, sanitary and functional manner to protect residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life and individuality for four residents (Resident council group) of five residents reviewed for dignity, from a total sample of 18 residents, resulting in the potential for feelings of inferiority, depression, and loss of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to act promptly on grievances reported in resident council meetings and provide responses to grievances in five of five residents, as reported during a confidential resident council interview, in a total sample of 18 residents and a total census of 84 residents, resulting in unresolved resident concerns and decreased quality of life.

Inspectors wroteThis Citation Pertains To Intake #MI00138037 Based on observation, interview, and record review, the facility failed to report allegations of abuse for four (Resident #18 and 65) of 4 reviewed, resulting in allegations of abuse that were not reported and the potential for further allegations of abuse to go unreported.

Inspectors wroteThis Citation Pertains To Intake #MI00138037 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for two (Resident #18 and 65) of 4 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for one (Resident #50) of one reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. According to the clinical record Resident # 50 (R50), was admitted to the facility with diagnosis that included RHEUMATOID ARTHRITIS, shoulder replacement and major depression. R50 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) further record review reflected R50 was transferred to the hospital on [DATE] and 7/25/23. On 09/19/23 at 09:52 AM, during a bed side interview with Resident # 50 , he stated he had been to hospital twice this year and was not given information about returning to the facility or what the process was to hold his bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one (Resident #19) of 18 reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs.

Inspectors wroteThis Citation Pertain To Intake #MI00139343 Based on interview and record review, the facility failed to develop and implement an effective patient centered discharge planning process for one resident (#48) of one reviewed for discharge planning, resulting in frustration, anger and an against medical advice discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for two (Resident #12, #38) of four reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health. Resident #12 Review of the medical record revealed that Resident #12 (R12) was readmitted to facility 5/16/22 with diagnoses including unspecified dementia, morbid obesity, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/23 revealed that R12 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (severe cognitive impairment). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent and accurately assess pressure ulcers for one resident (R32) of 3 residents reviewed resulting in delayed treatment of the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive smoking equipment for 1 of 1 resident reviewed for smoking (Resident #27), resulting in a burn.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a toileting program in one of one residents was reviewed for bowel and bladder incontinence (Resident #27), resulting in continued incontinence, decreased quality of life, and risk of skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutritional supplements and alternate foods per resident preferences in one of four reviewed for weight loss (Resident #46), resulting in a severe weight loss in one month and the potential for continued weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from a total of twenty-nine opportunities for three residents (Resident #69, #14 and #61) of four reviewed for medication administration, resulting in a medication error rate of 10.34% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely follow up with dental care for two residents (Resident #18 and #27) of 3 residents reviewed resulting in potential for tooth issues and unmet dental needs. Finding Include: Resident #18 (R18) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R18 admitted to the facility on [DATE] with diagnoses of dementia, anemia, severe protein-calorie malnutrition. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R18 was cognitively intact. During an interview on 09/18/23 at 08:13 AM, R18 was sitting on his bed, was alert and well groomed. R18 said that he has a loose tooth and it scares him. R18 showed surveyor the loose tooth and pushed it out with his tongue. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food tray products effecting Resident #30 and all residents who consume room food trays, resulting in decreased food acceptance and nutritional decline in a current facility census of residents. Based on observation, interview, record review, 4 of 5 from the confidential group meeting, and 2 (15, 24) of 18 total sampled residents, the facility failed to provide palatable food products effecting 54 residents, resulting in decreased food acceptance and reduced caloric intake. Review of the medical record revealed Resident #30 (R30) was admitted to the facility on [DATE] with diagnoses that included lung and liver cancer, Chronic Obstructive Pulmonary Disease and Sepsis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor residents' food preferences and serve warm food on the menu for one resident (R30) one reviewed, resulting in resident not receiving food of their choice and experiencing dissatisfaction during dining. Findings Include: Review of the medical record revealed Resident #30 (R30) was admitted to the facility on [DATE] with diagnoses that included lung and liver cancer, Chronic Obstructive Pulmonary Disease and Sepsis. According to Resident #30 (R30)'s Minimum Data Set (MDS) dated [DATE], revealed R30 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R30 requires minimal assistance with activities of daily living and ambulation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) use gloves during eye drop administration for one resident (#69) and 2) routinely change and store oxygen tubing off floor for one resident (#19) from a total sample of 18 residents, resulting in the potential for cross-contamination, spread of infection, and facility acquired infections.