The Villa at West Branch: Hospice Care Failures - MI
The incident at The Villa at West Branch occurred during the final days of Resident #701's life, when the person had declined to the point where they no longer wanted to feed themselves. Federal inspectors found that staff recognized clear signs of distress but didn't ensure proper medical oversight during the critical transition period.
CNA Q, who cared for the resident, told inspectors the patient "was moaning and flinching" and described how dramatically the person had deteriorated. "Resident #701 was a lot better than that," the nursing assistant said. "They were eating and was getting up. When Resident #701 started not wanting to feed themselves, we knew they were declining."
The most alarming moment came when hospice nurses arrived to assess the situation. "I remember when the hospice nurse came in, Resident #701 was running a fever and when we rolled the resident, they were just screaming in pain," CNA Q told investigators.
When inspectors asked whether the resident's skin felt hot to the touch, CNA Q confirmed: "Yes, very hot."
The nursing assistant acknowledged informing "the nurse" about the resident's condition, but inspection records suggest the facility failed to follow its own detailed protocols for managing hospice patients and notifying physicians of significant changes.
Federal investigators found that the facility's written policies required immediate action in exactly this type of situation. The Villa's "Change in a Resident's Condition or Status" policy, revised in February 2021, states that nurses must "promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status."
The policy specifically requires physician notification for "significant change in the resident's physical/emotional/mental condition" and "need to alter the resident's medical treatment significantly."
According to facility documents, a significant change of condition is defined as "a major decline or improvement in the resident's status" that "will not normally resolve itself without intervention by staff," "impacts more than one area of the resident's health status," and "requires interdisciplinary review and/or revision to the care plan."
Resident #701's combination of high fever, severe pain response, and inability to self-feed clearly met these criteria.
The facility operates under a dual-responsibility system for hospice care that requires careful coordination between nursing home staff and hospice providers. The Villa's hospice policy, revised in July 2017, outlines specific responsibilities for each party.
Hospice services handle "medical direction, nursing and clinical management of the terminal illness" and provide "medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms."
But the nursing home retains critical oversight duties, including "administering prescribed therapies" and "notifying the hospice about a significant change in the resident's physical, mental, social, or emotional status."
The policy requires staff to alert hospice providers about "clinical complications that suggest a need to alter the plan of care" and mandates "communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day."
CNA Q's account suggests the facility relied on the hospice nurse's presence to address the resident's deteriorating condition rather than following established notification protocols. The nursing assistant said "it was the hospice nurse who said to take Resident #701's vitals," indicating the clinical assessment came from the visiting hospice staff rather than facility-initiated physician contact.
This approach appears to contradict the facility's own policies requiring proactive communication about significant changes in resident status.
The inspection occurred in August 2025 following a complaint about the facility's handling of the situation. Federal investigators classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents, but the finding highlights broader concerns about end-of-life care coordination.
The case illustrates the complex challenges nursing homes face when managing hospice patients, where multiple providers must coordinate care during residents' most vulnerable moments. Clear communication protocols become critical when patients can no longer advocate for themselves or clearly express their needs.
Resident #701's experience also demonstrates how quickly conditions can deteriorate in terminally ill patients, making timely physician notification essential for appropriate pain management and comfort care adjustments.
The facility's detailed policies suggest administrators understood these responsibilities. The hospice protocol specifically acknowledges that nursing homes must maintain "twenty-four-hour room and board care" while ensuring hospice providers can "manage the resident's care as it relates to the terminal illness and related conditions."
But having comprehensive policies means little if staff don't implement them during critical moments when residents are suffering.
CNA Q's recollection that the resident "was a lot better than that" just days or weeks earlier underscores how rapidly end-stage patients can decline, creating urgent situations that require immediate clinical response rather than waiting for scheduled hospice visits.
The nursing assistant's observation that "when Resident #701 started not wanting to feed themselves, we knew they were declining" suggests staff recognized the significance of the change but may not have connected it to the facility's formal notification requirements.
Federal inspectors found that the facility failed to demonstrate proper implementation of its own protocols during this critical period in Resident #701's final days, when the person needed coordinated medical attention most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At West Branch from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
The Villa at West Branch in West Branch, MI was cited for violations during a health inspection on August 22, 2025.
Federal inspectors found that staff recognized clear signs of distress but didn't ensure proper medical oversight during the critical transition period.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.