The Villa at City Center

In the surveyor’s words

From the most serious findings on record at The Villa at City Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 31, 2022

  Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to provide goods, services and necessary care and to prevent neglect from occurring by its failure to administer medications, perform treatments, and complete assessments on the 7:00 PM to 7:00 AM shift on 08/02/22 and 08/16/22. An Immediate Jeopardy (IJ) occurred when, on 8/2/22 on the 7:00 PM to 7:00 AM shift, a nurse for the 1-East Unit did not report for work. The on-site nursing staff did not assume the duties of the nurse. An Agency nurse replaced the nurse at approximately 11:00 PM on 8/2/22 but did not perform the scheduled medications and assessments for the evening of 8/2/22. […]

• Immediate jeopardy, patternF880May 19, 2021

  Based on observation, interview, and record review, the facility failed to properly maintain infection control practices per the Centers for Disease Control and Prevention (CDC) guidelines, resulting in sustained spread of COVID-19, the likelihood for continued exposure/transmission of COVID-19 for up to 141 facility residents, facility staff members, and potential decline in overall health which resulted in Immediate Jeopardy. Findings Include: Licensed Practical Nurse (LPN A) tested positive for COVID-19 in the middle of their shift on 4/12/21 at approximately 2:30 PM. […]

• Immediate jeopardy, isolatedF694Aug 31, 2022

  Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to provide quality of care in accordance with professional standards of practice for 3 resident's (Resident #24, Resident #86, and Resident #138), with Intravenous catheters (IV's) and subcutaneous fluid administration (Hypodermoclysis) by ensuring that the residents had 1) Current physicians' orders for use, maintenance and monitoring of the sites, administration of fluids/medications, line flushes, dressing changes and discontinuation of the catheter and 2) Documentation of care, to aid in preventing serious complications/harm, including, inflammation, pain, blood clots, infections, Central Line Associated Blood Stream Infections (CLABSI), hospitalization s and/or… […]

• Actual harm, isolatedF600Mar 2, 2023

  This citation pertains to Intake MI00134689. Based on observation, interview, and record review, the facility failed to protect the resident's (R702's) right to be free from sexual abuse by another resident (R701), resulting in R702 experiencing unwanted sexual touching and advances, disturbed sleep with feelings of distress and sadness, and the potential for ongoing and/or future decreased psychosocial well-being. Findings include: A facility-reported incident (FRI) submitted to the State Agency included the following allegation: It was reported a male resident was sexually aggressive toward a female resident. […]

• Actual harm, isolatedF684Aug 31, 2022

  Based on interview and record review, the facility failed to assess, monitor, and provide timely interventions for 2 residents (Resident #117 and Resident #143) of 35 residents reviewed from a census of 139 residents, resulting in Resident #117 transferring to the hospital and Resident #143 dying while both developed changes of condition without nursing assessments to aid in identifying a decrease in cognition and an overall decline in condition. Findings Include: Resident #117: A review of the Face Sheet and MDS assessment indicated Resident #117 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]