Villa at Pine Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jul 21, 2023

  This citation pertains to Intake Number(s): MI00136993. Based on interview and record review, the facility failed to accurately assess, monitor, and treat a wound for one (R803) of four residents reviewed for skin management and changes in condition. This resulted in an Immediate Jeopardy (IJ) to the health and safety of residents when a wound to R803's left great toe that was present for an undetermined amount of time was not identified or treated by the facility and resulted in a hospital transfer, diagnoses of sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) due to an infected wound with gas gangrene (a serious soft tissue infection caused by bacteria that produces gas and toxins) which required… […]

• Actual harm, isolatedF689Aug 21, 2025

  This citation relates to Intake #2571092. Based on observation, interview, and record review, the facility failed to prevent an avoidable fall out of bed for one Resident (R8) of five resident reviewed for falls, resulting in actual harm for R8, who sustained a femur fracture. Findings include: Review of a complaint received by the State Agency on 7/24/25 revealed an allegation that R8 fell out of bed while they were cleaned by nursing staff and rolled over onto the floor. The complaint alleged R8 had one person assisting them and said they were supposed to have two-person assistance. The concern further revealed that R8 was hospitalized and subsequently treated for a fractured right hip. […]

• Actual harm, isolatedF686May 22, 2025

  This citation pertains to intake: MI00152863. Based on interview and record review the facility failed to accurately assess a sacral/coccyx wound, implement adequate and appropriate interventions to prevent wound development, failed to timely identify the decline of a sacral/coccyx wound and notify the Physician for one (R202) of two residents reviewed for pressure wounds, which resulted in hospitalization for an infected wound, sepsis and a Stage 4 Pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacral/coccyx. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns regarding R202's pressure wounds. […]

• Actual harm, isolatedF692Apr 4, 2024

  This citation pertains to Intake #MI00143695. Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R907) of two residents reviewed for nutrition and weight loss. This deficient practice for a resident admitted with higher risk resulted in decreased intake, significant undetected weight loss, and overall decline in the status. Findings include: R907 A record review revealed R907 was admitted to the facility for a short-term stay, after hospitalization on [DATE]. R907's admitting diagnoses included respiratory failure, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease (COPD). […]

• Actual harm, isolatedF684Nov 1, 2023

  This citation pertains to intake: MI00140321. Based on interviews and record reviews the facility failed to timely provide medical care and ensure a timely transfer to the hospital for a resident identified with a change of condition (R84) and failed to ensure monitoring of oxygen saturation levels for (R81), two residents of two residents reviewed for a change of condition, resulting in the delayed treatment of a resident (R84) with identified acute changes who was later transferred to the hospital, intubated, and admitted into the Intensive Care Unit (ICU). […]