The Villa at West Branch

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman's office of pending transfers/discharges for the last three years and for two residents (Resident #6, Resident #10) 2 residents reviewed for hospitalization, resulting in the lost opportunity of the State Office of Long-Term Care Ombudsman's office to offer additional support and advocacy to the residents with no notice of pending transfers/discharges for 3 years.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program including 1) Accurate outcome and process surveillance comprising identification of potential trends and a system to identify and prevent spread of potential infections and communicable disease 2) Hand hygiene during meals, 3) Enhanced Barrier Precautions for one resident (Resident #12), 4) Cleaning of multi-resident use glucometers, and 5) Maintenance of indwelling urinary catheters in a sanitary manner for one resident ( Resident #11) resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dignity of residents by not answering residents' call lights in a timely manner for 6 of 7 confidential residents from the Resident Council Group, and 1 resident (Resident #57) of 20 sampled residents reviewed for dignity, resulting in anger, frustration, depression, verbalizations of being embarrassed, and a resident soiling themself. Findings Include: Resident #57:Review of the Face Sheet, nurse's notes, Cognitive assessment tool (BIMS), dated 3/12/26, and care plans, dated 12/25 to 6/26, revealed Resident #57 was [AGE] years old, alert (BIMS of 14), her own person, admitted to the facility on [DATE], dependent on staff for Activities of Daily Living/ADL. The residents' diagnosis included Depression, Anxiety, Bipolar, Fibromyalgia, obesity, difficulty walking, and chronic kidney disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage, dispose of expired medications, date multi-dose open medications/treatments and date a glucometer stick bottle for 2 of 4 carts reviewed and 2 of 2 treatment carts reviewed and for two residents (Resident #39, Resident #59), resulting in expired medications/treatments, opened and undated medications/treatments, and medications left at residents' bedsides. Findings Include: Resident #39: Review of the Face Sheet, orders dated 8/26, and nursing note's dated 5/26 through 6/26, revealed, Resident #39 was [AGE] years old, admitted to the facility on [DATE], had a cognitive assessment score dated 1/5/26, of 5 (BIMS-5: cognitively impaired), and was dependent on staff for all Activities of Daily Living/ADL's. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement procedures and monitoring to ensure the assessment and clinical appropriateness of medication self-administration for one resident (Resident #55) of one resident reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Activities of Daily Living (ADL) care, including clean bedding and bathing per preference, was provided to two residents (Resident #12 and Resident#55) of two residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to implement procedures to ensure weight monitoring for two residents (Resident # 10 and Resident #50) of four residents reviewed for nutrition resulting in a lack of weight monitoring for residents with a known risk for nutrition deficiencies and with significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for the care and management of respiratory equipment and the administration of oxygen per Health Care Provider (HCP) orders for two residents (Resident #50 and Resident #55) of two residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate narcotic count and documentation of controlled substance usage for 1 of 4 medication carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for personal in-room refrigerator food storage, monitoring and disposal for one resident (Resident #56) of one resident reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the daily posting of nurse staffing data was posted in a prominent place, included the hours worked of licensed and unlicensed nursing staff, and accurate documentation of staff numbers and actual hours worked, resulting in incomplete and inaccurate nurse staffing information.

Inspectors wroteThis Citation pertains to Intake Numbers 2575723 and 2589048. Based on interview and record review, the facility failed to operationalize procedures to ensure a timely response, appropriate coordination of care, and comprehensive/accurate documentation for a change in condition for one resident (Resident # 701) of three residents reviewed, resulting in a lack of comprehensive assessment, a lack of coordination with Hospice services and unnecessary pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications, medical supplies, labeling and storage in 3 of 4 medication carts and 1 of 2 medication rooms, resulting in a medication cart being left unlocked and unattended, a lack of dating of multi-dose medications after opening, and the potential for residents to receive medications with altered efficiency.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure proper sanitization and food handling processes in the kitchen for 57 of 57 Residents who eat food prepared in the kitchen, resulting in the potential for contamination, consumption of expired food items, and food borne illness

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program, encompassing outcome and process surveillance including surveillance resulting in lack of accurate and comprehensive infection tracking, surveillance and data monitoring/analysis and failed to ensure a urinary catheter drainage bag was maintained off the floor for one resident (Resident #4) of two residents reviewed resulting in the potential for infection and the likelihood for spread of microorganisms and illness to all 58 facility residents. F indings include: An interview was and review of facility IC data was completed with IC Licensed Practical Nurse (LPN) M and the Director of Nursing (DON) on 4/29/25 at 12:41 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when three medication errors were observed from a total of 25 opportunities for two residents (#36, #37) of five residents reviewed. This deficient practice resulted in a medication error rate of 8% and the potential for the risk of adverse medication effects and decreased medication efficacy.

Inspectors wroteBased on interview and record review the facility failed to ensure that arbitration agreements were explained in a manner that can be understood for three residents (R9, R35, R213) and 6 of 6 residents in resident council reviewed for arbitration agreements, resulting in residents being unsure of what they signed and agreed to.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were treated in a dignified manner for three residents (R4, R108, R208) of 16 residents reviewed for dignity, resulting in uncovered urine collection bags and lack of respect for residents individuality.

Inspectors wroteBased on interview and record review, the facility failed to ensure that advance directive forms were completed by a designated responsible party for one resident (Resident #8) of two residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement procedures to ensure Activity of Daily Living (ADL) care per preference was provided to one resident (Resident #13) of two residents reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders for administration of oxygen, update care plans for oxygen administration and maintain oxygen supplies in a sanitary manner for three residents (R16, R23 and R211) of four residents reviewed for respiratory care, resulting in inaccurate care plans, inaccurate and missing oxygen administration orders and improper storage of nebulizers and oxygen tubing.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for bed rail use for one resident (#47) of four residents reviewed for accidents/hazards resulting in a lack of health care provider orders and assessment/monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain informed consents for psychotropic medications for one resident (Resident #43) of 5 residents reviewed for unnecessary medications, resulting in a lack of informed consent prior to initiation and administration of psychoactive medications.

Inspectors wroteBased on observation, intervention and record review, the facility failed to ensure that meal items were provided per the menu and failed to ensure residents were notified of menu changes for all facility residents who eat in the kitchen including one resident (# 16) of four residents reviewed and a confidential group of residents resulting in verbalization of feelings of frustration and discontent with food and meals.

Inspectors wroteThis Citation pertains to Intake Number MI00144251 Based on interview and record review the facility failed to 1. Complete a bowel assessment and monitoring with resident's complaints of pain and rectal bleeding; 2. Document the clinical rationale for the administration of an enema and 3. Perform the proper administration of an enema for one resident (Resident #61), resulting in the inappropriate administration of an enema, multiple partial thickness anal mucosa tears, full thickness rectal tear and partial thickness anal mucosa laceration that required surgical repair. Findings Include: Resident #61: On 5/6/2024 at 11:40 AM, a review was completed of Resident #61's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses of Anemia, Chronic Kidney Disease, Diabetes and Heart Disease. Resident #61 was cognitively intact and able to make his needs known. [...]

Inspectors wroteThis Citation Pertains to Intake Numbers MI00134226, MI00134335, and MI00136587. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedure for pressure ulcer (wounds caused by pressure) prevention and management and ensure accurate and complete documentation for four residents (Resident #9, Resident #36, Resident #59, and Resident #67) of four residents reviewed, resulting in a lack of implementation of planned and meaningful interventions, pressure ulcer development, pressure ulcer worsening, unnecessary pain, and the likelihood for decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to date and label food items, ensure cold milk, prevent cross-contamination with serving, and a spoiled loaf of bread in the nourishment room for all 56 Residents that receive meals from the kitchen, resulting in food items with no prepared dates, a milk temperature of 51.6 degrees, cross-contamination of food item with serving and a nourishment room loaf of wheat bread having blue/gray fuzzy substance (mold).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure code status accuracy for six residents (#4, #8, #22, #29, #36, #40) of six residents reviewed for advance directives, resulting in Resident #22's record having conflicting code status documented and Residents #4, #8, #29, #26 and #40 DNR order forms were inaccurately completed. Findings Include: Resident #4: During initial tour on [DATE], Resident #4 was observed self-propelling throughout the hallway. She was well groomed and appeared to be in good spirits during the short interaction. On [DATE] at 1:40 PM, a review was completed of Resident #4's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Intracerebral Hemorrhage, Kidney Disease, Major Depressive Disorder and Polyneuropathy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure accurate dispensing, administration, and reconciliation of controlled substances in one of three medication carts reviewed, resulting in inaccurate narcotic medication reconciliation, undocumented narcotic medications, improperly stored controlled substances, and the potential for controlled substance diversion and medication errors with adverse effects for all 56 facility residents.

Inspectors wroteThis Citation has two Deficient Practice Statements. Deficient Practice Statement One: Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance and accurate data collection/documentation/analysis resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, accessibility of hand hygiene supplies/functioning equipment, and the likelihood for spread of microorganisms and illness to all 56 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that planned interventions for fall prevention were in place for one resident (Resident #14) of two residents reviewed, resulting in a lack of implementation of planned interventions for fall prevention and the potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to to change a urinary catheter causing recurrent urinary tract infections (UTI) for one resident (Resident #18), resulting in Resident #18's urinary catheter not being changed per physician's orders, which caused recurrent urinary tract infection with the likelihood for prolonged illness and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions to prevent weight loss for two residents (Resident #18, Resident #50) of 16 residents reviewed for weight loss, resulting in Resident #18 to experience a 5.79% weight loss in 60 days and Resident #50 to experience a 12.30% weight loss. in 30 days.

Inspectors wroteBased on interview and record review, the facility failed to provide proper antibiotic therapy for wound culture organism for one resident (Resident #36) of two residents reviewed, resulting in Resident #36 receiving Rocephin antibiotic therapy for 7 days prior to wound culture results for wound infection with no susceptibility to the antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to justify the use of a PRN (as needed) antianxiety medication and document the rationale for indefinite use for two residents (Resident #46, Resident #48) of 4 residents reviewed, resulting in the likelihood for unnecessary medications and adverse effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were observed for two residents (Resident #7 and Resident #18) from a total of 27 observations, resulting in a medication error rate of 7.4%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to lack of implementation of standards of practice for medication administration and incorrect administration dosage.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility's Fourth Quarter 2023 third party payroll services submitted the Payroll-Based Journal (PBJ) data timely, resulting in the second quarter (April/May/June) 2023 payroll submission to trigger for staffing concerns by CMS.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and justify the administration of an antibiotic for one resident (Resident #36) of two residents reviewed, resulting in Resident #36 receiving an antibiotic without appropriate clinical rationale and the possibility of antibiotic resistance due to inappropriate usage.

Inspectors wroteThis Citation Pertains to Intake MI00138286 Based on observation, interview and record review, the facility failed to implement and operationalize pressure ulcer (wounds created by pressure) care, per Health Care Provider (HCP) order and professional standards of practice, for one resident (Resident #701) of three Residents reviewed. This deficient practice resulted in lack of effective collaboration and communication between external wound care HCP and facility nursing staff, lack of implementation of ordered wound care treatments, lack of completion of ordered wound care treatments, lack of clear and concise wound documentation, lack of wound assessment/monitoring following debridement, development and worsening of pressure ulcers, and Resident #701 requiring emergency medical treatment and blood transfusions due to unidentified bleeding from debrided pressure ulcer.