The Villa at Rose City

In the surveyor’s words

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

• Immediate jeopardy, patternF880Dec 6, 2021

  Based on observation, interview, and record review, the facility is placed in Immediate Jeopardy for its failure to implement a complete Infection Control Program designed to provide a safe environment and to help prevent the spread of COVID-19 (Coronavirus Disease of 2019) and other communicable diseases and/or infections. This deficient practice has five noted deficiencies: COVID-19 1. Identify and delineate positive COVID-19 residents from persons under investigation (PUI-residents who have recently recovered and/or had been exposed to COVID-19 without testing positive. 2. Follow transmission-based precautions for staff and residents for COVID-19 positive and PUI residents. 3. […]

• Immediate jeopardy, isolatedF684Mar 28, 2022

  This Citation is linked to Intake Number MI 914 This citation has two separate Deficient Practice Statements (DPS) A and B: DPS A: Based on interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to assess and monitor, 2) Failure to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice led to actual death for Resident #2 who had a significant drop in blood pressure, became hypoglycemic and unresponsive. Resident #2 was transported to the local hospital by local Emergency Medical Services (EMS) for further evaluation and emergency medical treatment. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. […]

• Actual harm, isolatedF689Oct 24, 2024

  This Citation pertains to Intake Number MI00147582. Based on observation, interview and record review, the facility failed to provide appropriate supervision, follow and implementtimely interventions for three residents (Resident #1,Resident #2 and Resident #3) of three residents reviewed for falls, resulting in repeated unwitnessed falls, an eyebrow laceration, right hip and left hip fractures with the likelihood of further falls and/or injuries. Findings include: Resident #1: On 10/23/2024, at 10:00 AM, Resident #1 was resting in a reclined geri-chair in the therapy room with the speech therapist. […]

• Actual harm, isolatedF600Mar 25, 2024

  Based on interview and record review, the facility failed to ensure adequate staff training and supervision during facility van transportation and appropriate emergency medical response for one (#216) of one resident reviewed resulting in the wheelchair lift platform not being raised during Resident removal from the facility transportation van, Resident #216 being pulled out of the van in their wheelchair without the platform lift elevated, falling, and experiencing unnecessary pain, lacerations, multiple soft tissue injuries, a cervical spine (neck) fracture, and psychosocial distress utilizing the reasonable person concept. Findings include: An interview was conducted with Anonymous Witness M on 2/16/24 at 10:00 AM. […]

• Actual harm, isolatedF686Mar 25, 2024

  Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management and care, including timely and appropriate wound identification for four residents (Resident #22, Resident #23, Resident #30, and Resident #37) of seven residents reviewed, resulting in a lack of proper identification and care of Resident #22's and Resident #23's pressure ulcers, Resident #30 developing an unstageable Deep Tissue Injury (DTI- area of damage to underlying tissue with unknown depth) pressure ulcer, and Resident #37 developing a DTI pressure ulcer, unnecessary pain, and the likelihood for further pressure ulcer development and a decline in overall condition. […]