The Villa at West Branch

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 8, 2022

  This Citation pertains to Intake Numbers MI00132816, MI00133022, and MI00133025 and contains two Deficient Practice Statements (DPS). DPS One pertains to Intake Number MI00133022. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to implement and operationalize its policies and procedures to prevent the willful resident-to-resident sexual abuse of one resident (Resident #904) of eight residents reviewed, resulting in Resident #905, a cognitively-intact male, luring and sexually assaulting Resident #904, a severely cognitively-impaired female who lacked the ability to consent, into performing sexual acts on him for approximately seven minutes in the central dining room of the facility. […]

• Immediate jeopardy, isolatedF684Mar 30, 2022

  This Citation Pertains to Intake Numbers MI 995 and MI 157. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to develop, implement, and operationalize policies and procedures for comprehensive assessment and monitoring per professional standards of practice for two residents (Resident #704 and Resident #707) of three residents reviewed. This deficient practice resulted in 1) A lack of routine staff monitoring of Resident #704 from 2:53 AM to 6:59 AM on [DATE]. Resident #704 was without ordered supplemental oxygen during that timeframe, was found unresponsive, and required emergency medical treatment including mechanical ventilation due to hypoxemia (decreased oxygen levels). […]

• Actual harm, isolatedF684May 9, 2024

  This Citation pertains to Intake Number MI00144251 Based on interview and record review the facility failed to 1. Complete a bowel assessment and monitoring with resident's complaints of pain and rectal bleeding; 2. Document the clinical rationale for the administration of an enema and 3. Perform the proper administration of an enema for one resident (Resident #61), resulting in the inappropriate administration of an enema, multiple partial thickness anal mucosa tears, full thickness rectal tear and partial thickness anal mucosa laceration that required surgical repair. […]

• Actual harm, isolatedF686May 9, 2024

  This Citation Pertains to Intake Numbers MI00134226, MI00134335, and MI00136587. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedure for pressure ulcer (wounds caused by pressure) prevention and management and ensure accurate and complete documentation for four residents (Resident #9, Resident #36, Resident #59, and Resident #67) of four residents reviewed, resulting in a lack of implementation of planned and meaningful interventions, pressure ulcer development, pressure ulcer worsening, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #9: On 5/6/24 at 11:10 AM, Resident #9 was observed sitting in a powered wheelchair in their room. […]

• Actual harm, isolatedF686Sep 7, 2023

  This Citation Pertains to Intake MI00138286 Based on observation, interview and record review, the facility failed to implement and operationalize pressure ulcer (wounds created by pressure) care, per Health Care Provider (HCP) order and professional standards of practice, for one resident (Resident #701) of three Residents reviewed. This deficient practice resulted in lack of effective collaboration and communication between external wound care HCP and facility nursing staff, lack of implementation of ordered wound care treatments, lack of completion of ordered wound care treatments, lack of clear and concise wound documentation, lack of wound assessment/monitoring following debridement, development and worsening of pressure ulcers, and Resident #701 requiring emergency medical treatment… […]