The Villa at Great Lakes Crossing

In the surveyor’s words

From the most serious findings on record at The Villa at Great Lakes Crossing, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 11, 2024

  This citation pertains to intake #MI00148730 Based on observation, interview, and record review, the facility failed to ensure the use of an appropriate wheelchair for one resident (R902) of three residents reviewed for accidents, resulting in a fractured tibia and fibula (the two long bones in the lower leg that connect the knee to the ankle). Findings include: An anonymous complaint received by the State Agency alleged R902 was not placed in an appropriate wheelchair for transport and sustained a broken tibia and fibula. On 12/11/24 at 9:34 AM, a power wheelchair was observed in the hallway outside R902's room. It was observed the power chair had very long and wide foot rests to prevent feet from slipping off the foot rests. On 12/11/24 at 9:38 AM, R902 was observed in their bed. […]

• No harm, potential for more than minimal, widespreadF809Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents. Findings:On 2/18/26 at 11:30 AM, during observation of kitchen lunch service with AM Cook/Manager-in-Training (MiT) D, Dietary Manager (DM) F, and Regional Dietary Director (RDD) K, the steam table was set with pans of food ready to be served to facility residents. The following was noted while obtaining the temperatures of food on the steam table:- The mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls.- The vegetables designated for the residents on a pureed diet contained pieces of pea-sized vegetables.- No pans of pureed meat were present.-… […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to: 1. Ensure wall surfaces were in good repair and cleanable; 2. Ensure light fixtures, vents, and a resident refrigerator were maintained in a clean and sanitary manner; 3. Ensure cleaned ladles were properly stored; and 4. Properly date-label food in the resident refrigerators. Findings include: On 2/18/26 at 8:47 AM, a tour of the kitchen was conducted with AM [NAME] and Manager in Training (MIT) D and then with Dietary Manager (DM) F. The following items were noted: The wall behind the clean pot/pan shelving unit showed surface damage and paint loss from repeated impact. Two wall panels beside the three-compartment sink drainboard were detached, exposing the raw block wall behind them. […]

• No harm, potential for more than minimal, widespreadF908Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure the reach-in cooler, located in the dietary office, was maintained in good working order. Findings include: On 2/18/26 at 9:09 AM, during a tour of the kitchen with Dietary Manager (DM) F, the following was noted: - The temperature log for the reach-in cooler located in the dietary office documented the following AM temperatures:2/15/26: 49 F (Fahrenheit).2/16/26: 48 F2/17/26: 44 F2/18/26: 45 F- The thermometer inside of the reach-in cooler registered 47 F.- The gasket for the left positioned cooler door was not installed which kept the cooler door ajar, causing the internal temperature to rise above safe levels. […]

• No harm, potential for more than minimal, patternF636Feb 20, 2026

  Based on interview and record review the facility failed to complete and/or ensure the timely completion of comprehensive resident assessments (a complete interdisciplinary evaluation of a resident's physical , mental, psychosocial and functional status) in accordance with regulatory requirements for 13 residents (R4, R6, R33, R53, R72, R93, R94, R95, R101, R114, R124, R125, and R139) out of 13 residents reviewed for Minimum Data Set (MDS) assessment accuracy and timeliness.Findings include:During record review the following was identified: R4 Record review of R4's electronic medical record revealed admission into facility on 2/19/25 with a pertinent diagnosis of schizophrenia (mental disorder). […]