Villa at Pine Place

Inspectors wroteThis citation pertains to intake 3006555 and 3009286. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (R802) of two residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation relates to Intake #2571092. Based on observation, interview, and record review, the facility failed to prevent an avoidable fall out of bed for one Resident (R8) of five resident reviewed for falls, resulting in actual harm for R8, who sustained a femur fracture.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene for two residents (R#'s 58 and 65) of seven residents reviewed for infection control as well as ensure appropriate infection control practices in the facility laundry and with regards to staff fingernails. This deficient practice had the ability to affect all residents at the facility.

Inspectors wroteThis citation pertains to intake #1233191. Based on observation, interview, and record review the facility failed to ensure treatment in a dignified manner for five residents, (R20, R24, R43, R70, and R76) of six residents reviewed for dignity.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, homelike environment for multiple residents, including R60.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent staff from handling resident's money (cash and cards) to purchase smoking materials for 18 (6, 11, 14, 16, 26, 29, 30, 31, 37, 40, 42, 45, 47, 50, 55, 63, 64, and 67) of 18 residents reviewed for abuse, resulting in the potential for exploitation and misappropriation of the resident's property.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for four residents (R1, R24, R43, and R70) of 10 residents reviewed for dining/nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen and during food service for one resident (R70) and all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to intake #1233191. Based on interview and record review, the facility failed to promote the resident's right to be treated with dignity and respect for one (R49) of six residents reviewed for dignity, resulting in facility staff searching a resident's personal possessions without giving the resident the opportunity to decline, in absence of concern with illegal substances, and implementing smoking suspension for three days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pull cord for the overbed light was accessible to the resident for one (R60) of one resident reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to protect resident privacy for one (R25) of two resident reviewed for privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect, for one Resident (R10) of two residents reviewed for abuse, resulting in R10 being transferred from their wheelchair with a damaged Hoyer lift sling, hitting their head and causing pain, with the potential to affect 15 additional facility residents who used Hoyer lifts for transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care for one (R60) of one resident reviewed for bladder and bowel incontinence.

Inspectors wroteBased on observation, interview and record review the facility failed to provide snacks for a resident with low body weight for one (R54) of three residents reviewed for nutrition.

Inspectors wroteThis citation pertains to intake: MI00152863. Based on interview and record review the facility failed to accurately assess a sacral/coccyx wound, implement adequate and appropriate interventions to prevent wound development, failed to timely identify the decline of a sacral/coccyx wound and notify the Physician for one (R202) of two residents reviewed for pressure wounds, which resulted in hospitalization for an infected wound, sepsis and a Stage 4 Pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacral/coccyx.

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 wroteBased on observation, interview, and record review, the facility failed to provide consistent, meaningful and person-centered activities for one (R32) of one resident reviewed for activities, and five of seven residents who attended the confidential Resident Council interview, resulting in potential for loss of interaction, joy, self-esteem, sense of well-being, creativity, and independence.

Inspectors wroteThis citation pertains to intake #'s MI00146644 and MI00146449. Based on observation, interview and record review, the facility failed to ensure liquids were provided according to their prescribed therapeutic diet texture for one resident (R57) of four residents reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the total amount of physician ordered enteral (tube) feeding, document consistently and accurately the amount of enteral feeding infused, and ensure timely follow up with the physician for one (R63) of one resident reviewed for enteral feeding.

Inspectors wroteThis citation pertains to intake #MI00146644. Based on interview and record review the facility failed to administer pain medication for one resident (R273) of three residents reviewed for pain management.

Inspectors wroteBased on interview and record review facility failed to consistently assess a resident after dialysis; and maintain accessible communication/collaboration between the dialysis center and the facility for one (R4) of one resident reviewed for dialysis.

Inspectors wroteBased on interview and record review facility failed to provide sufficient staff to provide adequate care and services for residents on the weekends for three of seven residents who attended the Resident Council interview who wished to remain anonymous, resulting in extended call light response and resident dissatisfaction. This deficient practice had the ability to affect multiple residents that resided in the facility.

Inspectors wroteR12 On 9/11/24 The medical record for R12 was reviewed and revealed the following: R12 was initially admitted to the facility on [DATE] and had diagnoses including Schizoaffective disorder, Bipolar disorder and Anxiety disorder. A Physicians order dated 8/28/24 revealed the following: diazePAM Oral Tablet 2 MG (Diazepam) Give 1 mg by mouth every 8 hours as needed (PRN) for anxiety for 14 Days. A review of the EMAR progress notes (electronic medication administration record) for August and September 2024 revealed the following dates of R12's diazepam administration in which no documented non-pharmacological interventions were attempted prior to administration: 9/11, 9/10 (7:45 PM), 9/10 (10:19 AM), 9/9 (4:59 PM), 9/9 (9:36 AM), 9/8 (8:24 PM), 9/8 (6:12 PM), 9/8 (8:14 AM), 9/7 (12:13 PM), 9/6, 9/3, and 9/2/24. [...]

Inspectors wroteThis citation pertains to intake #'s MI00146644 and MI00146449. Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were applied for one residents (R12) of two residents reviewed for Pressure Ulcers .

Inspectors wroteBased on interview and record review the facility failed to operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for use of antibiotic medications for three (R4,R8 and R63) of five residents reviewed for antibiotic stewardship program, resulting in the potential for increased antibiotic resistance.

Inspectors wroteThis citation pertains to Intake # MI00145010 Based on interview and record review, the facility failed to accurately transcribe admission orders and follow up timely for one (R504) of two Residents reviewed for admission orders, resulting in R504 missing four days of their medications, including their blood thinner, diabetic, blood pressure and Gout medications.

Inspectors wroteThis citation pertains to Intake# MI00144079 Based on observation, interview and record review the facility failed to complete a full investigation following an allegation of resident-to-resident sexual abuse pertaining to two residents (R701 and R706 ) out of four residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #MI00144079. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address history of drug use for one (R702) of two reviewed for comprehensive care plans.

Inspectors wroteThis citation pertains to intake #MI00144079 and MI00144102. Based on observation, interview and record review, the facility failed to prevent an elopement of one (R704) of residents reviewed for accidents/supervision, resulting in R704 exiting the facility's front door and gone for four and a half hours without staff being aware.

Inspectors wroteThis citation pertains to intake #MI00144079 and MI00144102. Based on observation, interview and record review, the facility failed to ensure that medically-related social services and follow up to address guardianship, patient advocacy, and care planning reviews for one (R704) of one residents reviewed for social services.

Inspectors wroteThis citation pertains to Intake #MI00143695. Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R907) of two residents reviewed for nutrition and weight loss. This deficient practice for a resident admitted with higher risk resulted in decreased intake, significant undetected weight loss, and overall decline in the status.

Inspectors wroteThis citation pertains to Intake # MI00142974 Based on interview and record review the facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, (using McGeer's Criteria for the definition of infections), as well as calculated infection rates, demonstrated on-going tracking, trending, in-services, education, and environmental rounding. resulting in the R902 developing a change of condition resulting in hospitalization related to a Urinary Tract Infection.

Inspectors wroteThis citation pertains to Intake # MI00143570 Based on observation, interview, and record review facility failed to follow-up and resolve a grievance timely for one (R901) of one Resident reviewed for grievances resulting in feelings of frustration.

Inspectors wroteThis citation pertains to Intake# MI00142589 Based on observation, interview and record review the facility failed to ensure routine scheduled bathing and facial hair removal was provided for two (R702 and R703) out of three residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteThis citation pertains to intake #MI00141561. Based on observation, interview, and record review the facility failed to ensure freedom from experiencing and overhearing verbal abuse for two residents (R#'s 704 and 706) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake: MI00140321. Based on interviews and record reviews the facility failed to timely provide medical care and ensure a timely transfer to the hospital for a resident identified with a change of condition (R84) and failed to ensure monitoring of oxygen saturation levels for (R81), two residents of two residents reviewed for a change of condition, resulting in the delayed treatment of a resident (R84) with identified acute changes who was later transferred to the hospital, intubated, and admitted into the Intensive Care Unit (ICU).

Inspectors wroteThis citation pertains to intake: MI00140321. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on interview and record reviews the facility failed to ensure a resident was properly transferred via wheelchair (R84) and ensure the required assistance level for bed mobility was provided to prevent a fall (R17), two of three residents reviewed for accidents, resulting in the resident to have verbalized pain, and ultimately resulting in an identified acute nondisplaced fracture at the proximal tibial meta diaphysis (R84).

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 wroteThis citation has two deficient practice statements. Deficient Practice #1 Based on interview and record review, the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, and record review the facility failed to consistently ensure the physicians review, action and rationale of identified medication irregularities documented by the Pharmacy monthly medication reviews were documented and maintained in the resident's medical record for four residents (R17, R25, R36 and R41) of six residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents prescribed psychotropic medication had adequate indication for use of duplicate antidepressants, clinical rationale to support continued use, as well as PRN (as needed) orders, identify and monitor resident specific behaviors and approaches, and document non-pharmacological approaches and behavior details at the time of medication administration for two (R17 and R36) of six residents reviewed for unnecessary medication, resulting in unnecessary use of psychotropic medication, and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two medication carts were secured while unattended and ensure medications were properly stored and secured, resulting in the potential for unauthorized entry into the carts, misuse, contamination and diversion. This deficient practice had the potential to affect multiple residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one (R10) of two residents reviewed for medication were assessed for the safe self-administration of medication and to have medication kept at bedside.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure healthcare treatment decisions were properly documented for one (R17) of five reviewed for advanced directives/code status.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to consistently notify the resident's legal guardian of refusals of their medications for one (R5) of one resident reviewed for notification of change.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an effective program to initiate and resolve grievances for one (R67) of three reviewed for dignity/respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order with medical symptom justification for the use of a physical restraint and specify the times to be used while in bed per plan of care for one (R36) of two residents reviewed for physical restraints.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate Nursing practices were followed for two residents (R25 and R50) of two residents reviewed for Nursing standards of practice when facility Nursing staff did not timely transcribe a Physician order for R25 and failed to ensure medications were reordered and available for administration for R50.

Inspectors wroteThis citation pertains to intake #MI00140514. Based on interview and record review, the facility to ensure accurate and complete discharge instructions were provided to one resident upon discharge (R80) of one residents reviewed for discharge planning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure restorative range of motion (ROM) services and hand splints were applied for two (R17 and R41) out of three residents reviewed for limited ROM/Positioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper management of tube feeding, including labeling on the formula to ensure appropriate administration in accordance with physician orders for one resident (R21) of one resident reviewed for tube feeding, resulting in the potential for inaccurate tube feeding administration.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to consistently coordinate and provide breakfast meals for one resident (R44) of one reviewed for dialysis, resulting in frustration and hunger.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate narcotic medication practices including: storage and destruction of narcotics, and administration and disposition discrepancies for controlled substances for one (R36) of two residents reviewed for controlled substances, and one resident who attended the confidential resident council interview, resulting unrelieved pain for residents that reported they weren't getting their controlled pain medication at times, and the potential for unidentified diversion of controlled substances.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain a medication error rate of less than five percent when two medication errors were observed from a total of 25 opportunities observed during medication administration, resulting in a medication error rate of 8%.

Inspectors wroteBased on observation, interview, & record reviews the facility failed to ensure seizure medications were administered per the manufacturer instructions and physician orders for one (R22) of four residents reviewed for the medication administration observation, resulting in two significant medication errors.