Westland, a Villa Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's right to smoke for one resident (R167) of three reviewed for self-determination.

Inspectors wroteThis citation pertains to Intake 3012716. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for one resident (R57) by another resident (R102).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for Post-Traumatic Stress Disorder (PTSD) and discharge planning care plans for three residents (R5, R112 and R223) out of three reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate grooming care for one (R76) of three residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply heel protectors per physician orders for one resident (R16) out of two reviewed for skin conditions.

Inspectors wroteBased on interview, and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS-an assessment to detect involuntary movement) assessment for one resident (R27) out of five reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (medication rate 6.67%) for two residents (R6 and R23) of eight resident observed during the medication pass observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate medical record for one resident (R210) out of two reviewed for medical records.

Inspectors wroteThis citation pertains to Intake 2978833. Based on interview and record review, the facility failed to permit one resident (R700) out of three residents reviewed for discharges, to return to the facility after a hospitalization. Findings Include: A review of documentation submitted to the State Agency (SA) revealed the following, Complainant states the facility called the police and had [them] sent to the hospital for a psych (psychiatric) evaluation on the evening of 04/07/2026. The complainant states [they the hospital] cleared his evaluation and is ready to be sent back to the facility, but [facility] staff told the hospital they won't accept [them] back . On 4/16/26 at 10:32 AM, R700 remained hospitalized and was interviewed via phone. They explained they were transported to the local hospital and evaluated by psychiatric services. [...]

Inspectors wroteThis citation pertains to Intake 2978833. Based on observation, interview, and record review, the facility failed to implement supervision interventions after an incident of alleged inappropriate touching for two residents (R705 and R706) of two reviewed for adequate supervision.

Inspectors wroteThis citation pertains to intake 2588154. Based on observation, interview, and record review, the facility failed to maintain clean and sanitary shower beds affecting two residents (R900 and R902) out of three residents reviewed for infection control.

Inspectors wroteThis citation pertains to Intake: MI00153897 Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency for one resident (R901) of one reviewed for staff to resident abuse.

Inspectors wroteThis citation pertains to Intake number: MI00153419. Based on observation, interview, and record review, the facility failed to thoroughly assess and determine the root cause of a skin impairment for one (R801) of one resident reviewed for skin management.

Inspectors wroteThis citation pertains to Intake number: MI00153419. Based on observation, interview, and record review, the facility failed to provide medically related social services for one (R801) of one resident reviewed for mood and behaviors who had a history of self harm and repeatedly contacted 911(emergency medical services).

Inspectors wroteThis citation pertains to intake M100152760: Based on observation, interview, and record review, the facility failed to prevent the misappropriation of medication for one (R703) of three residents reviewed for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to receive unopened and private mail delivery was maintained for two of eight confidential residents who attended a resident group interview.

Inspectors wroteOn 03/18/25 at 2:20 PM, room [ROOM NUMBER] was observed. The flooring was soiled with stains, and was sticky and dull in appearance. The bathroom flooring was also soiled with a buildup of grime. The over-bed table in the room was observed with the plastic edging pulling away from the surface, leaving rough, exposed particle board underneath. The surface was no longer smooth and easily cleanable. On 03/18/25 at 2:25 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding 7-8 floor tiles. On 03/18/25 at 2:30 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding several floor tiles. When queried about the black substance, Regional Housekeeping Supervisor stated, It looks like built up glue. Resident (R92), who resided in room [ROOM NUMBER] was queried about the room. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete in-service education performance reviews for five Certified Nurse Aides (CNA's Z, AA, BB, CC, and DD) of five reviewed for an annual performance review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, storage of nebulizer mask for two residents (R32, R655), clean blood pressure cuffs, and elements of the infection control program were completed potentially affecting all 194 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Mental Illness/Intellectual Disability Related Condition Level 1 Screening and failed to complete a Level II evaluation for four residents (R44, R177, R4 and R10) out of five reviewed for PASARR's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for four residents ( R30, R53, R69, R154) of six residents reviewed for food palatability.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted regularly for one resident (R133) of one resident reviewed for care conferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity during tube feeding, for one resident (#43) of three residents reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one resident (R70) and provide a proper fitting wheelchair for one resident (R131) out of two residents reviewed for accomodation of needs. Findings Include: R70 On 3/17/25 at 6:45 PM, R70 was observed sitting on their bed. The call light was observed hanging out of reach above the resident's bed. R70 was asked how they're supposed to use their call light if it's out of reach, and they stated, How do you use it? A review of R70's medical record revealed they were admitted into the facility on 2/23/23 with diagnoses that included Alzheimer's Disease, Diabetes and Muscle Weakness. Further review of the resident's medical record revealed the resident was independent to extensve assistance for activities of daily living. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure updated and accurate advanced directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (R2) of two residents reviewed for advanced directives.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate a verbal altercation for two residents (R199 and R197) of six residents reviewed from abuse.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) Mental Illness/Intellectual Disability Related Condition Level 1 Screening and failed to complete a Level II evaluation for one resident (R3) out of five reviewed for PASARR's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plan interventions for two residents (R13 and R196) of three residents reviewed for care planning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two (R4 and R44) of three residents had timely revisions for care plans.

Inspectors wroteThis citation pertains to Intake MI00150867. Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance, and ensure bathing was provided per the plan of care for two residents (R32 and R177) of nine residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to schedule a follow up ophthalmology appointment in a timely manner for one resident (R146) out of one reviewed for vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accident-free environment for one resident (R177) out of one reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin for the collection of bowel movement) care for one resident (R32) out of one reviewed for colostomy care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was readily accessible for all 194 residents, families, and visitors in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the medication regimen irregularities were reviewed, acted upon, and documented in the medical record for one resident (R32) of six residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to complete an initial Abnormal Involuntary Movement Scale (AIMS) assessment for one resident (R44) out of one reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule recommended dental services for one of one resident (R133) reviewed for dental services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functional call light for one resident (R61) of one resident reviewed for operational call lights.

Inspectors wroteThis citation pertains to Intake: MI00149925 Based on observation, interview, and record review, the facility failed to implement a hand splint for one resident (R500) out of one resident reviewed for range of motion.

Inspectors wroteThis citation pertains to intake MI00149935. Based on observation, interview, and record review, the facility failed to properly store medications for one resident (R500) out of one resident reviewed for medication storage.

Inspectors wroteThis citation pertains to Intake MI00149448. Based on interview and record review, the facility failed to ensure laboratory (lab-blood sample) tests were completed timely for two resident (R901, R902) of three whose blood test results were reviewed, resulting in labs not completed and a delay in health assessment.

Inspectors wroteThis citation refers to Intake MI00146945. Based on interview and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for one resident (R904) out of two residents reviewed for abuse resulting in hospitalization for right eye fracture.

Inspectors wroteThis citation pertains to Intake #MI00147007. Based on observation, interview, and record review, the facility failed to prevent an accident for one Resident (R905) of three residents reviewed for accidents.

Inspectors wroteThis citation pertains to MI00147006. Based on observation, interview and record review the facility failed to maintain a clean and homelike environment affecting eight rooms reviewed for environmental concerns.

Inspectors wroteThis citation pertains to Intake MI00143993. Based on observation and interview, the facility failed to maintain a clean, homelike environment for one resident R701 out of one resident reviewed for environment.

Inspectors wroteThis citation pertains to Intake MI00143350. Based on interview, and record review, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for one resident (R804) out of one reviewed for PASARR screenings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change and date a peripherally inserted central catheter (PICC) line dressing for one resident (R802) out of one reviewed for PICC line dressings.

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 183 residents who receive meal services (12 nothing by mouth residents, or NPO) out of the facility's total census of 195 residents.

Inspectors wroteThis citation pertains to intake MI00142158. Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 195 residents and its staff resulting in an increased potential for harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the call light within reach for one (R141) of three residents reviewed for call light accessibility.

Inspectors wroteThis intake pertains to Intake MI00140161. Based on interview, and record review, the facility failed to ensure advance directives were in place for one resident (R68) out of two reviewed for advance directives. Findings Include: A review of Intake called into the State Agency noted the following, We also discussed (R68) mental status and whether (R68) is mentally competent at this point, as (R68) has vascular dementia. I was told by the social worker (SW) A .that they were placing a consult for a psychiatrist to come evaluate (R68) and determine if (R68) is competent or not. SW A explained that this was to be done by the end of that week. SW A also explained that [they] would call me and let me know the results, as I told SW A that I would need to file for guardianship if R68 is deemed incompetent. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nail care for one (R76) of 27 residents reviewed for activities of daily living (ADLs).

Inspectors wroteThis citation has two deficient practices. Deficient practice statement number one. This citation pertains to Intakes MI00136356 and MI00139987. Based on observation, interview, and record review the facility failed to provide timely tracheotomy care (surgical opening through the neck to help oxygen reach the lungs), obtain a sputum culture, and follow up on recommendations by the Respiratory Therapist, for two residents (R60 and R600) reviewed for tracheotomy care.

Inspectors wroteBased on interview and record review, the facility failed to include a 14-day stop date on a PRN (as needed) anti-anxiety medication for two (R6, R74) of six residents reviewed.

Inspectors wroteThis citation pertains to Intake MI00140161. Based on interview and record review, the facility failed to provide routine dental care to one resident (R68) out of one reviewed for dental care. Findings Include: On 2/7/2024 at 12:44 PM, an interview was conducted with Family Member (FM) B. FM B stated that they were concerned about R68's dental care. FM B stated that they don't know the last time R68 had seen a dentist, and they believe that R68 is supposed to have some teeth pulled. FM B stated that they have reached out to facility staff, but they do not get back with them. A review of the medical records revealed that R68 re-admitted into the facility on 7/5/2023 with the following medical diagnoses, Major Depressive Disorder and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 8/15 indicating an impaired cognition. [...]