The Villa at the Bay

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686May 26, 2021

  Based on observation, interview, and record review, the facility failed to assess, monitor, and implement interventions to prevent the development and worsening of facility acquired pressure injuries for three Residents (#22, #66, #126) out of five residents reviewed for pressure injury. This caused actual harm to Resident #126 who developed an avoidable stage 4 pressure injury to the sacrum and a stage 4 pressure injury to the heel, which resulted in continued deterioration in overall function, reduced quality of life and pain. Resident #66 sustained harm due to worsening of their sacral pressure injury, and Resident #22 was put at increased risk for worsening of their facility-acquired pressure injury due to the systemic breakdown in pressure injury prevention and management. […]

• Actual harm, isolatedF684May 22, 2025

  Intake: MI00150656 This citation has two separate deficiencies. Based on interview and record review, the facility failed to provide all necessary care and services for one resident (R128) of one resident reviewed for quality of life, resulting in R128 not maintaining his highest practicable well-being, being hospitalized three times and endangering his life. Findings include: Review of R128's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including multiple right rib fractures and alcohol dependence with withdrawal. R128 was his own responsible party for medical and financial decisions. Review of R128's Discharge Summary from [Hospital Name] dated 3/4/25 read, in part, .Patient is a pleasant 78 y.o. […]

• Actual harm, isolatedF686May 22, 2025

  Based on observation, interview, and record review, the facility failed to readily identify, promote healing, and prevent the development of pressure injuries for two Residents (#26 & R42) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R26 developing a stage 3 pressure ulcer that worsened into a stage 4 pressure ulcer, and R42 developing infection and the deterioration of pressure wounds. Findings include: Resident #42 (R42) The medical record for R42 revealed an admitted to the facility on [DATE] with a primary diagnosis of pneumonia. R42 had a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating intact cognition. […]

• Actual harm, isolatedF684Feb 20, 2025

  This citation pertains to intake numbers; MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure 1. New admission orders were double checked, 2. Appropriate assessments and wound care were provided, and 3. Timely notification of a change in condition were completed per professional standards for one Resident (#3) of three residents reviewed for new admissions, resulting in R3 being transferred to the emergency department with post-surgical infection, respiratory distress, low blood pressure, sepsis, and subsequent death. […]

• Actual harm, isolatedF686Jul 17, 2024

  Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two Residents (R9, R18) of four residents reviewed for pressure ulcers. This deficient practice resulted in the development of one unstageable pressure ulcer and the potential for development of new/additional pressure ulcers. Findings include: Resident #18 (R18) Review of R18's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including right tibia fracture, right fibula fracture and nutritional deficiency. […]