The Villa at Traverse Point

In the surveyor’s words

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

• Immediate jeopardy, patternF700Aug 27, 2026

  This deficient practice pertains to Intake #3120666.Based on observation, interview, and record review, the facility failed to:Complete comprehensive bed rail assessments to determine initial resident need and continued need for bed rails,Trial or provide rationale against less restrictive alternatives to bed rail use,Assess all residents with bed rails for risk of entrapment and ensure the absence of bed entrapment zones through consistent and scheduled measurements by facility staff, and/orEnsure informed consent was obtained prior to installation of bed rails.This deficient practice resulted in an Immediate Jeopardy (IJ) due to the death of one Resident (#1) and the likelihood of entrapment and/or serious harm for four additional Residents (#2, #3, and #4) out of four residents reviewed… […]

• Immediate jeopardy, patternF600Jul 11, 2022

  This citation pertains to Intakes #MI 046, #MI 044, #MI 222, #MI 046, and #MI 044. Based on observation, interview, and record review, the facility failed to ensure freedom from abuse for 10 Residents (#27, #50, #42, #35, #6, #18, #56, #64, #3, and #171) of 25 residents reviewed for abuse. This deficient practice resulted in pain, bruising, humiliation, embarrassment, fearfulness, increased anxiety, frustration, and feelings of being unsafe in the facility based on a reasonable person standard for residents with impaired cognition and verbalizations by cognitively intact residents resulting in an Immediate Jeopardy (IJ) to vulnerable resident's health and safety. […]

• Immediate jeopardy, isolatedF695Mar 23, 2021

  This citation contains 2 Deficient Practice Statements. Based on observation, interview and record review, the facility failed to provide appropriate [MEDICAL CONDITION] (a tube inserted through the neck into the windpipe to serve as an airway) care according to facility policy and professional standards of practice for one Resident (#55) of one resident reviewed for [MEDICAL CONDITION] care. This deficient practice resulted in Immediate Jeopardy, placing Resident #55 at risk for serious harm, injury or death when (1) on [DATE] Resident #55 was admitted to the facility with a [MEDICAL CONDITION] and no physical orders were in place for suctioning, emergency care or assessment of Resident #55's [MEDICAL CONDITION], (2) no evaluation had been completed to evaluate Resident #55's self-care of… […]

• Actual harm, patternF610Jul 11, 2022

  This citation refers to intakes MI# 222, 046, and 044. Based on observation, interview, and record review, the facility failed to ensure that all allegations of abuse were fully investigated for six Residents (#3, #35, #50, #64, #65, #171) out of 25 reviewed for abuse and neglect. This deficient practice resulted in incomplete abuse investigations which resulted in perpetrators being allowed to continue working putting the entire resident population at risk. Findings include: Resident #171 A review of a facility incident report investigation provided by the Administrator on 6/29/22 revealed the following: . On 4/28/22 at 6:30 AM, CNA (CNA D) was walking along the hall to do rounds and observed (Resident #171) seated on the floor through the doorway. […]

• Actual harm, isolatedF677Jul 11, 2022

  This citation pertains to Intake #MI 222 Based on observation, interview, and record review, the facility failed to ensure assistance with incontinence care and showers for ten dependent Residents (#18, #24, #34, #64, #61, #14, #30, #33, #56, and #51) of 25 residents reviewed for Activity of Daily Living (ADL) assistance. This deficient practice resulted in actual harm for Resident #18 with the development of moisture associated skin damage (MASD) due to prolonged skin contact with urine and/or feces. Resident #18 had the likelihood of discomfort and feelings of embarrassment, frustration, and anger. Findings include: Resident #18 According to the Minimum Data Set (MDS) assessment, dated 4/14/22, showed Resident #18 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]