St. Joseph's, A Villa Center
St. Joseph's, A Villa Center in Hamtramck, MI — inspection on March 26, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
asked about the late assessments and reported, both residents were Medicaid only and did not need
235383 03/26/2026
St.
Joseph'S, A Villa Center 9400 Conant Street Hamtramck, MI 48212
physician's orders noted the following, Date:1/16/2026 .Out of bed daily in wheelchair to tolerance
.Status: Active .On 3/25/2026 at 9:52 AM, R79 was observed up in their wheelchair. R79 reported they used to wear a boot on their right foot but had not worn them in quite some time. No padded boot was observed on the right foot, or leg rest pad to protect the RLE (right lower extremity). R79 reported they felt as though they still needed to wear the boot and leg rest pad.
The medical record revealed R79 admitted into the facility on 1/12/2026 with the following medical diagnoses, Peripheral Vascular Disease and Polyneuropathy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental (BIMS) status score of 12/15, indicating an impaired cognition.
R79 also required staff assistance for bed mobility and transfers. On 3/25/2026 at 11:44 AM, R79 was observed in the therapy room and up in the wheelchair. No padded boot was observed on the right foot, or leg rest pad to protect the RLE.On 3/25/2026 at 12:58 PM, R79 was observed in the chair and eating lunch. R79 reported they would like to wear the boot and have the leg rest padding applied because they had been up for a while at this point and their foot was hurting. On 3/26/2026 at 9:28 AM, an interview was conducted with the Director of Rehabilitation (DOR).
The DOR stated when R79 admitted into the facility, they were in a different disposition than they are now and is doing much better.
The DOR stated they would have to check into it (padded boot and leg rest pad).On 3/26/2026 at 11:41 AM, an interview was conducted with the Director of Nursing (DON).
The DON reported R79 was evaluated by therapy, and the order was to remain active as R79 still needed the interventions in place.A facility policy related to application of protective appliances was requested and not received by the end of survey.
235383 03/26/2026
St.
Joseph'S, A Villa Center 9400 Conant Street Hamtramck, MI 48212
prevent accidents.
observation, interview, and record review, the facility failed to ensure the resident's environment was
3/24/2026 at 10:40 AM, R58 was observed lying in bed in a low position. R58's right side of the bed was against the wall with the left side open to the room.
Observed on the floor next to the bed was a floor mat that appeared to be torn in the middle and curled up towards the ends of the mat. A review of R58's medical record revealed, R58 was admitted to the facility on [DATE] with diagnosis of Dementia, severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance. A review of R58's Minimum Data Set (MDS) noted R58 with moderately impaired cognition and required some assistance with activities of daily living by staff. A review of R58's progress note, revealed the following, 1/27/2026 13:45 (1:45 PM) Incident/Accident: Writer observed resident on the floor in front of her wheelchair during rounds.
Writer asked the resident where she had been trying to go; resident responded, I don't know.A review of R58's care plan noted, Focus: I had an actual fall d/t (due to) to my behaviors, impulsiveness, Poor Balance, Dementia, poor communication/comprehension, Psychoactive drug use, unsteady gait, Encephalopathy.
Date Initiated: 02/13/2026 Goal: The resident's injuries will resolve without complication by review date.
Date Initiated: 02/23/2024.
Interventions: Landing mat implemented at bedside when in bed.
Date Initiated: 02/23/2024.On 3/26/2026 at 12:37 PM, the Nursing Home Administrator was asked about the observation of R58's floor mat and reported the fall mats condition are to be checked daily.
235383 03/26/2026
St.
Joseph'S, A Villa Center 9400 Conant Street Hamtramck, MI 48212
review of the medical record showed R154 was admitted into the facility on 3/13/26 with diagnoses
levels). A review of the most recent MDS (minimum data set) of R154 showed a BIMS (brief interview for mental status) of 15/15, indicating fully intact cognition.A review of the medication orders of R154 revealed the following active orders:1.Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (microgram per actuation) (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally in the morning for SOB (shortness of breath)/Asthma. D/C (discontinue) Trelegy when Fluticasone/Salmetrol 100/50 mcg inhaler arrives.2.
Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/DOSE (Fluticasone-Salmeterol)1 inhalation inhale orally every 12 hours for Asthma.A review of the March 2026 MAR (medication administration record) for R154 showed both of these medications were administered from March 19th through March 25th.On 03/25/2026 at 9:27 AM, an interview was conducted with Unit Manager B.
They stated Trelegy had been ordered for R154 as a therapeutic interchange until they were able to start taking Advair.
Unit manager B confrimed the order indicated Trelegy should be stopped when Advair was started.
Unit manager B opened the medication cart, and both inhalers were observed to be present for R154.On 03/25/2026 at 9:34 AM, an interview was conducted with RN (Registered Nurse) C and said they administered both inhalers to R154 that morning.A review of a facility policy titled, Medication Orders did not address unnecessary medications.
235383 03/26/2026
St.
Joseph'S, A Villa Center 9400 Conant Street Hamtramck, MI 48212
in accordance with accepted professional standards.
information in the medical record for one resident (R57) out of two reviewed for medical records.
stated they were doing much better since they completed therapy and was looking to discharge home soon.A review of the medical record revealed R57 admitted into the facility on 1/16/2026 with the following medical diagnoses, Metabolic Encephalopathy and Obstructive and Reflux Uropathy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental status (BIMS) score of 6/15, indicating an impaired cognition. R57 also required staff assistance with bed mobility and transfers. A review of the progress notes revealed the following provider note, Effective date: 3/18/2025 .PLAN: Obstructive Uropathy-(name of indwelling catheter) in place-Monitor closely for urinary retention-Patient will need outpatient follow up with urology .On 3/24/2026 at 12:57 PM, R57 reported they no longer had the indwelling catheter in place. R57 reported they were voiding well and did not believe they needed it put back in place. R57 reported they had not had the indwelling catheter in place for about 2 weeks now and they were using a urinal to void.On 3/25/2026 at 9:40 AM, an interview was conducted with Unit Manager (UM) B. UM B reported R57 removed (pull out) their indwelling catheter on 3/13/2026 and would not let the nurse reinsert it. UM B reported the physician was notified regarding R57 no longer having an indwelling catheter and they were unsure why it was documented in the medical record that R57 still had one inserted.On 3/26/2026 at 11:30 AM, an interview was conducted with the Director of Nursing (DON).
The DON reported providers should be reviewing their notes for accuracy and R57 no longer has the indwelling catheter in place and will be following up with urology soon.A request for a facility policy related to accurate medical records was requested and not received by the end of survey.
235383 03/26/2026
St.
Joseph'S, A Villa Center 9400 Conant Street Hamtramck, MI 48212
single resident rooms.
minimal harm Based on observation and interview, the facility failed to provide 80 square feet per resident in multiple resident rooms, for 16 of 49 multiple resident rooms (#'s 112, 113, 114, 115, 116, 118, 119,
include:On 3/24/26 at 1:30 PM, observation of resident rooms and review of the facility bed count information revealed the following rooms that did not meet the minimum requirement of 80 square feet per resident: ROOM SQ. FT # OF BEDS112 282 4 113 282 4 114 282 4 115 282 4 116 282 4 118 282 4 119 282 4 120 282 4 122 282 4 123 282 4 124 282 4 210 282 4 213 282 4 214 286 4215 286 4 216 286 4On 3/25/26 at 2:45 PM, when asked about the insufficient square footage in some of the resident rooms, the Administrator stated there was a remodeling plan in process, and that in the interim, residents who express a concern are offered a larger room if available.