Inspection Reports for The Villa at Parkridge
28 S Prospect St, Ypsilanti, MI 48198, United States, MI, 48198
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to immediately assess and notify the physician and responsible party of a fall with major injury for one resident.
Findings
The facility failed to document and notify the physician and responsible party about a resident's fall on 08/05/2025, which resulted in a fractured right hip requiring surgical repair. Nursing staff did not perform or document a full assessment, including range of motion or neuro checks, and notification was delayed until the day after the fall.
Complaint Details
This citation pertains to Intake #2589332. The complaint investigation found that the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for one resident. The fall was not documented on the day it occurred, and notification was delayed until the following day after therapy notified nursing and the resident's guardian was informed by the resident's roommate.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately assess and notify physician and responsible party of a fall with major injury | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Observed the resident on the floor, helped resident into bed, failed to notify physician and responsible party, and did not document the fall or assessments properly. |
| ADON C | Assistant Director of Nursing | Reported that nobody was aware of the fall until therapy notified her and explained the delay in notification to physician and responsible party. |
| DON B | Director of Nursing | Reported the expectation that after a fall or incident, the resident must be fully assessed and physician and responsible party notified. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Feb 13, 2025
Visit Reason
The inspection was conducted based on complaints and intakes related to resident grievances, care plan deficiencies, staffing concerns, food quality, and nutritional issues at The Villa at Parkridge nursing home.
Findings
The facility failed to address repeated resident concerns about food palatability, call light response times, and grievance resolution. Care plans for some residents were not revised after significant health changes. Staffing levels were insufficient to meet resident needs timely, resulting in long call light response times. Food was often served at unsafe temperatures and was unpalatable, affecting resident nutrition and satisfaction.
Complaint Details
The investigation was triggered by multiple intakes (MI00146664, MI00146710, MI00148581, MI00147352) involving resident grievances about food quality, staffing, care plan deficiencies, and call light response times. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to honor resident rights to organize and participate in resident/family groups; repeated concerns about food palatability, call light response, and grievance resolution were not addressed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to resolve grievances for one resident regarding missing clothing items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans for two residents after significant weight changes and hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary care and assistance with activities of daily living for two residents, resulting in unmet care needs and potential embarrassment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor preferences for weight management and prevent weight loss for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain sufficient nursing staff to meet residents' needs timely, resulting in long call light response times and unmet needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; personal food storage was inadequate. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 125
Weight loss: 11.7
Weight gain: 14.1
Call light response time: 45
Call light response time: 60
Meal trays observed: 25
Meal trays observed: 18
Food temperature: 132.4
Food temperature: 141.5
Food temperature: 133.4
Food temperature: 42.6
Food temperature: 43.8
Food temperature: 43.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Reported awareness of food and staffing concerns and new tracking process; stated staff should not turn off call lights until care is rendered. |
| Registered Dietician M | Registered Dietician | Interviewed regarding residents' nutritional status and care plans; reported unfamiliarity with Resident #374's case. |
| Certified Nursing Assistant X | Certified Nursing Assistant | Reported verbal notification of missing clothing items but no grievance form filed. |
| Environmental Services Director Y | Environmental Services Director | Reported all missing clothing items should go through grievance process. |
| Director of Nursing B | Director of Nursing | Reported meals should be care planned; acknowledged call light response concerns. |
| Activity Director T | Activity Director | Described efforts to engage residents in activities and challenges with resident participation. |
| Certified Nursing Assistant U | Certified Nursing Assistant | Described process for assisting residents to activities; new to floor. |
| Licensed Practical Nurse R | Licensed Practical Nurse | Reported CNA's ask residents for bath or shower preference; noted broken shower bench. |
| Certified Nursing Assistant Q | Certified Nursing Assistant | Reported giving bed bath due to broken shower bench. |
| Regional Maintenance Director S | Regional Maintenance Director | Reported shower bench was broken and would be fixed. |
| Staff Member O | Observed shutting off call light without providing requested service. |
Inspection Report
Complaint Investigation
Deficiencies: 17
Feb 13, 2025
Visit Reason
The inspection was conducted based on complaints and intakes MI00146664, MI00146710, MI00148581, MI00147352, and others, focusing on resident grievances, care quality, staffing, medication administration, food quality, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances related to food and staffing, inadequate grievance resolution, improper use and assessment of physical restraints, untimely significant change assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, insufficient assistance with activities of daily living, inadequate meaningful activities, failure to honor food preferences, unsafe medication administration, poor food palatability and temperature control, failure to provide medically related social services, insufficient staffing, and lack of collaboration with hospice providers.
Complaint Details
The investigation was complaint-driven based on multiple intakes including MI00146664, MI00146710, MI00148581, MI00147352, focusing on resident grievances, care quality, staffing, medication administration, food quality, and hospice services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to address and respond to repeated resident concerns related to food palatability, grievance resolution, evening snacks, and call light response. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to resolve grievances for one resident regarding missing clothing items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess bed bolsters as potential physical restraints for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a significant change Minimum Data Set (MDS) assessment timely for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate MDS assessments for six residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary care to assist two residents with activities of daily living, resulting in potential embarrassment and humiliation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide meaningful, individualized activities to one resident, resulting in potential for depression and boredom. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor preferences for weight management for one resident and prevent weight loss for another. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure assessment and monitoring of a dialysis access site and updated care plans for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain sufficient nursing staff to meet residents' needs timely for three residents and Resident Council. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide medically related social services for one resident, including addressing guardianship and care refusals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe storage and administration of medications, resulting in a medication error for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and drink were palatable, attractive, and at safe and appetizing temperatures, affecting multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident receives and the facility provides food that accommodates allergies, intolerances, and preferences, including gluten-free diet. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure collaboration of care and communication with the hospice provider for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer a pneumococcal immunization per consent for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 7
Residents reviewed: 25
Weight loss: 11.7
Weight gain: 14.1
Call light response time: 45
Call light response time: 60
BIMS score: 15
BIMS score: 3
BIMS score: 9
Temperature: 132.4
Temperature: 141.5
Temperature: 133.4
Temperature: 42.6
Temperature: 43.8
Temperature: 43.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Reported awareness of food and staffing concerns and new tracking process |
| Certified Nursing Assistant X | Certified Nursing Assistant | Reported knowledge of missing clothing items and grievance process |
| Environmental Services Director Y | Environmental Services Director | Reported grievance process for missing clothing items |
| Registered Nurse C | Registered Nurse | Reported use of bed bolsters and inability of resident to remove them |
| Certified Nurse Aide E | Certified Nurse Aide | Reported resident's transfer attempts and use of bed bolsters |
| RN/MDS Coordinator N | RN/MDS Coordinator | Reported on restraint assessments and MDS completion |
| Director of Nursing B | Director of Nursing | Reported on restraint definitions, staffing expectations, and hospice documentation |
| Licensed Practical Nurse H | Licensed Practical Nurse | Reported on resident falls and care plans |
| Certified Nursing Assistant K | Certified Nursing Assistant | Reported on resident falls and use of positioning wedges |
| MDS Nurse N | MDS Nurse | Reported on MDS coding errors and diagnosis removals |
| Certified Nursing Assistant P | Certified Nursing Assistant | Reported on dialysis access site knowledge and care plan use |
| Licensed Practical Nurse R | Licensed Practical Nurse | Reported on shower schedule and bed bath practices |
| Certified Nursing Assistant Q | Certified Nursing Assistant | Reported on shower bench being broken |
| Regional Maintenance Director S | Regional Maintenance Director | Reported on shower bench repair status |
| Registered Dietician M | Registered Dietician | Reported on diet preferences, weight management, and gluten-free diet substitutions |
| Social Worker I | Social Worker | Reported on guardianship and resident care refusals |
| Social Worker J | Social Worker | Reported on resident's refusal of care and guardian communication |
| Registered Nurse C | Registered Nurse | Observed medication administration and reported dialysis access site monitoring |
| Staff Member O | Observed shutting off call light without providing care | |
| Certified Nursing Assistant U | Certified Nursing Assistant | Reported on assisting residents to activities |
| Activity Director T | Activity Director | Reported on resident activity engagement and challenges |
| Assistant Director of Nursing Z | Assistant Director of Nursing/Infection Preventionist | Reported on pneumococcal immunization consent |
| Social Services Director SSD I | Social Services Director | Reported on hospice coordination |
| Director of Nursing DON B | Director of Nursing | Reported on hospice documentation and staffing expectations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 9, 2025
Visit Reason
The investigation was conducted due to a complaint regarding a resident (R101) who suffered burns after hot food was served at an unsafe temperature, resulting in injury and delayed treatment.
Findings
The facility failed to notify the physician promptly of a change in condition for R101 after a burn injury caused by hot noodles spilled on the resident. The burn was second-degree with open wounds and blistering. Staff did not follow reheating policies, failed to check food temperature, and delayed appropriate burn care. Education on reheating and burn treatment was lacking prior to the incident. The facility implemented corrective actions and monitoring after the incident.
Complaint Details
The complaint investigation focused on a burn injury to resident R101 caused by hot noodles spilled on himself due to staff failure to check food temperature and follow reheating policy. The burn was reported late to the physician and facility leadership. The resident experienced delayed treatment and pain. The facility implemented a plan of correction and monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify physician of change in condition for resident with burn injury, resulting in delayed treatment and increased risk of pain and infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary care and services to maintain highest practical physical level of well-being after burn injury, resulting in second-degree burns and delayed appropriate treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hot liquid/food was served at a safe and appropriate temperature, resulting in second-degree thermal burns to resident. | Level of Harm - Actual harm |
| Failed to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in resident burn injury. | Level of Harm - Actual harm |
Report Facts
Burn wound measurements: 4
Burn wound measurements: 4
Burn wound measurements: 8
Burn wound measurements: 3
Burn wound measurements: 8
Burn wound measurements: 6
Burn wound measurements: 5
Burn wound measurements: 5
Burn wound measurements: 8
Burn wound measurements: 4
Burn wound measurements: 8
Burn wound measurements: 8
Burn wound measurements: 5
Burn wound measurements: 5
Burn wound measurements: 7
Burn wound measurements: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager J | Nurse Manager | Reported RN H applied normal saline and first aid at time of burn and expected staff to notify physician and leadership. |
| RN H | Registered Nurse | Performed skin assessment, applied petroleum jelly and ABD dressing, did not notify physician or leadership. |
| CNA I | Certified Nurse Aid | Heated food for resident, did not check temperature, did not provide immediate first aid, notified RN H after incident. |
| Director of Nursing B | Director of Nursing | Reported no prior education on heating/reheating food, expected immediate notification of burns. |
| Nursing Home Administrator A | Nursing Home Administrator | Reported failure to follow reheating policy and lack of thermometer availability. |
| LPN C | Licensed Practical Nurse | Reported education on reheating policy after incident, unaware of immediate burn treatment policy. |
| CNA D | Certified Nurse Aid | Reported education on reheating policy after incident, unsure of temperature standards. |
| CNA E | Certified Nurse Aid | Reported education on reheating policy after incident, aware of resident's burn and pain complaints. |
| Assistant Director of Nursing O | Assistant Director of Nursing | First to contact physician, expected immediate first aid and notification, did not expect petroleum jelly use. |
| Wound Nurse P | Wound Nurse | Notified of burn wound, called physician for orders, expected immediate cooling and notification, verified dressing and treatment. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint intake MI00145665 regarding the facility's failure to notify a resident of grievance investigation outcomes and resolution.
Findings
The facility failed to notify Resident #2 of the resolutions to grievances she had submitted, despite documented concerns and stated resolutions. The Nursing Home Administrator could not demonstrate that the resident had been informed of grievance outcomes, contrary to facility policy requiring notification.
Complaint Details
This citation pertains to intake MI00145665. The complaint was substantiated based on observation, interview, and record review showing the facility did not notify Resident #2 of grievance resolutions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify Resident #2 of grievance investigation and resolution despite documented concerns and resolutions. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) A | Interviewed regarding grievance process and inability to demonstrate resident notification of grievance resolutions. |
Inspection Report
Routine
Deficiencies: 8
Feb 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, assessments, care planning, medication administration, foot care, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to promptly document and resolve resident grievances, inaccurate Minimum Data Set (MDS) assessments for several residents, incomplete care plans not reflecting resident preferences or fall interventions, improper insulin pen priming, inadequate foot care and podiatry follow-up, and poor maintenance and cleanliness of the physical plant.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure grievances were promptly documented, investigated, tracked and resolved for resident council members. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate coding on the Minimum Data Set (MDS) assessment for three residents, resulting in potential for inaccurate care plans and unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow-up with OBRA for one resident, resulting in potential for mismanaged mental health services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to include resident preferences in the plan of care for one resident, resulting in potential for anxiety and unmet preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise fall care plan after resident falls, resulting in potential for additional falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prime an insulin pen per manufacturer guidelines, resulting in potential for medication errors and adverse effects. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly assess and follow podiatry service orders for one resident, resulting in foot pain, skin breakdown, and delayed treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to effectively clean and maintain the physical plant, resulting in increased likelihood for cross-contamination, bacterial harborage, and reduced illumination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 24
Residents affected: 123
Falls: 2
Units of insulin: 14
Length of damaged wall surface: 6
Height of damaged wall surface: 5
Gap width: 1
Gap length: 42
Missing skin observations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Reported awareness of resident complaints and staff terminations related to call light response and staff attitudes; explained insulin pen priming procedure; discussed care plan expectations. |
| Nursing Home Administrator A | Nursing Home Administrator | Reported awareness of resident complaints and scheduled customer service in-services. |
| Registered Nurse C | Registered Nurse/MDS Coordinator | Reported inaccuracies in MDS coding for residents #41, #72, and #370. |
| Social Worker E | Social Worker | Discussed OBRA screening and follow-up for Resident #110; reported podiatry scheduling and communication. |
| Registered Nurse J | Registered Nurse | Reported knowledge of Resident #39's preferences and fall interventions; stated she did not update care plans for falls. |
| Certified Nurse Aid K | Certified Nurse Aid | Reported knowledge of Resident #39's routine and preferences. |
| Licensed Practical Nurse D | Licensed Practical Nurse | Observed preparing insulin pen incorrectly for Resident #74. |
| Wound Nurse D | Licensed Practical Nurse/Wound Nurse | Reported expectations for skin assessments and podiatry follow-up for Resident #40. |
| Director of Housekeeping and Laundry Services M | Director of Housekeeping and Laundry Services | Participated in environmental tour and described laundry aide schedules. |
| Regional Manager L | Regional Manager | Participated in environmental tour. |
| Director of Maintenance N | Director of Maintenance | Participated in environmental tour. |
| Regional Maintenance Director O | Regional Maintenance Director | Discussed facility work order system and maintenance concerns. |
| Licensed Practical Nurse R | Licensed Practical Nurse | Reported on skin assessment practices and familiarity with Resident #40. |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Reported on skin assessment practices and unfamiliarity with inspecting residents' feet. |
| Certified Nurse Aid P | Certified Nurse Aid | Reported completing skin assessments with showers and reporting abnormalities. |
Inspection Report
Annual Inspection
Deficiencies: 3
Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, activities, and facility safety at The Villa at Parkridge nursing home.
Findings
The facility failed to meet individualized activity needs for one resident, failed to properly assess and monitor wound dressings for another resident, and failed to provide backflow protection devices in two locations, resulting in potential risks to resident quality of life, wound infection, and water contamination.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to meet individualized activity needs for Resident #67, resulting in potential boredom and decreased quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess and monitor wound dressings for Resident #120, resulting in potential for wound infection not identified. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide backflow protection devices in two locations, risking contamination of the domestic water supply. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for activity needs: 4
Residents reviewed for wound care: 3
Dates of wound care documentation review: 11
Date of inspection completion: Aug 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Activities C | Director of Activities | Interviewed regarding Resident #67's participation in activities and transportation to outside events. |
| Director of Nursing B | Director of Nursing | Interviewed regarding Resident #120's wound care and awareness of maggots found in wound. |
| Licensed Practical Nurse M | Licensed Practical Nurse/Wound Nurse | Interviewed about wound dressing assessments and treatment orders for Resident #120. |
| Maintenance Director R | Maintenance Director | Interviewed regarding removal of hoses lacking backflow protection devices. |
Inspection Report
Routine
Deficiencies: 4
Aug 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care plans, activities, wound care, and medication administration at The Villa at Parkridge nursing home.
Findings
The facility failed to properly review and revise care plans for residents, meet individualized activity needs, assess and monitor wound dressings, and ensure medication error rates were below five percent, resulting in potential risks to resident care and safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to review, revise, and evaluate care plans for effectiveness for two residents, resulting in potential unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities to meet individualized needs for one resident, resulting in potential boredom and decreased quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess and monitor wound dressings in one resident, resulting in potential for wound infection not identified. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rate was less than five percent; nine medication errors observed in three residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for care plan review: 24
Medication errors observed: 9
Medication error rate: 23.68
Brief Interview for Mental Status (BIMS) score: 0
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 5
Brief Interview for Mental Status (BIMS) score: 0
Brief Interview for Mental Status (BIMS) score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse K | Unit Manager | Interviewed about Resident #8's care plan and shower schedule coordination with hospice |
| Director of Nursing B | Director of Nursing | Interviewed regarding care coordination with hospice and Resident #97's care plan and mobility |
| CNA L | Certified Nursing Assistant | Interviewed about shower schedule for Resident #8 |
| Licensed Practical Nurse N | Licensed Practical Nurse | Interviewed about Resident #97's mobility and preferences |
| Social Worker O | Social Worker | Interviewed about Resident #97's activity and socialization |
| Director of Activities C | Director of Activities | Interviewed about Resident #67's activity participation and facility outings |
| Licensed Practical Nurse M | Licensed Practical Nurse/Wound Nurse | Interviewed about wound care for Resident #120 |
| Licensed Practical Nurse D | Licensed Practical Nurse | Observed administering medications to Resident #59 with noted medication errors |
| Licensed Practical Nurse E | Licensed Practical Nurse | Observed administering medications to Resident #2 with noted medication errors |
| Registered Nurse F | Registered Nurse | Observed administering medications to Resident #69 with noted medication errors |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 7, 2023
Visit Reason
The inspection was conducted due to complaints and grievances raised by residents and their families regarding unresolved issues including call light response times, missing personal items, cold food, and staff communication.
Findings
The facility failed to promptly address resident council grievances and individual resident complaints, resulting in unresolved concerns such as delayed call light responses, missing dentures and clothing, cold food, and inadequate grievance documentation and follow-up. Several residents and family members reported dissatisfaction with the handling of grievances and quality of care.
Complaint Details
The complaint investigation involved 5 residents (Resident #65, 61, 49, 1, and 108) with issues including missing dentures and clothing, cold food, call light response delays, and unresolved grievances. The Nursing Home Administrator was often unaware of these concerns due to incomplete grievance documentation and follow-up. Family members expressed dissatisfaction with communication and care quality.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to act promptly on resident council grievances related to call light response time, staff communication, and cold food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to resolve grievances for 5 residents, including missing items, food complaints, and call light response times. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents interviewed in resident council meeting: 7
Residents reviewed for grievances: 25
Residents with unresolved grievances: 5
BIMS cognitive impairment scores: 5
BIMS cognitive impairment scores: 2
BIMS cognitive impairment scores: 14
BIM cognitive impairment scores: 3
BIM cognitive impairment scores: 9
Medication order date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding grievance follow-up and missing items |
| SW H | Social Worker | Reported grievance process and follow-up for missing items and resident concerns |
| Unit Manager I | Unit Manager | Reported awareness of missing dentures and resident concerns |
| LM M | Laundry Manager | Reported clothing labeling and grievance process for missing items |
| LPN Y | Licensed Practical Nurse | Mentioned in relation to discharge paperwork and medication administration |
| AM J | Activity Manager | Reported on resident interactions and staff-resident argument |
| UM I | Unit Manager | Involved in resident grievance discussions and staff communication |
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