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Complaint Investigation

The Villa At The Park

Inspection Date: September 17, 2025
Total Violations 8
Facility ID 235463
Location Highland Park, MI
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Inspection Findings

F-Tag F0550

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

This citation pertains to complaint 1310450 Based on observation, interview, and record review, the facility failed to ensure two confidential residents were treated with dignity and respect from a total census of 106.

Findings include:A review of the intake 1310450 revealed that several residents had concerns about the Activity Director (AD) and their interaction with the residents. One concern stated that the AD is rude, mean, disrespectful and uses profanity towards residents, anytime the residents ask for anything, the AD gets mad and cuts off the television as punishment. On 9/15/25 at 10:00 AM, an activity was observed occurring on the second floor. The activity staff was observed setting up resident for games and preparing music for an exercise activity. On 9/15/25 at 11:05 am, a confidential meeting of residents was held in the second-floor dining room. During the meeting, nine residents spoke of dissatisfaction with the AD saying .

they don't know what they are doing . they talk to us mean . talk to us inappropriate .we don't have activities for our age. We need better games . the activities can be better, and we can have more fun. During the meeting, residents also stated they have notified the administrator, and nothing has been done. On 9/17/25 while touring the facility, a resident who wished to remain confidential stated they had a problem with the AD. The resident stated, I don't like the AD, their attitude is bold, and they talk to us crazy when we go out and smoke, and they have discussed other residents' business with other residents. On 9/17/25 at 12:50 PM, an interview was held with a certified nursing assistant (CNA) who wished to remain confidential, said

they had witnessed the AD to withhold cigarettes or not provide activities on both floors and speak rudely to residents. On 9/17/25 at 2:00 PM an interview was held with the AD to discuss concerns. The AD revealed

they were new to the position at the building and had been working there since March. Their experience included having worked as an activity assistant at several other buildings. The AD stated the building and some of the residents are challenging, and they (the residents) were used to the prior director and now they are adjusting to changes. On 09/17/25 at 2:25 PM, the Director of Nursing (DON) was queried about the resident's concerns with the AD and indicated they were not aware of any pertinent concerns, but the Regional Director was. On 09/17/25 at 3:00 PM, the Regional Director was queried about the resident's concerns with the AD and stated that changes were coming. A review of the facility policy titled Dignity revealed the following: It is the policy of this facility to assure residents are treated in a manner that preserves the resident's dignity and promotes a quality life experience. PROCEDURE: 1. All residents will be treated with respect. 2. Resident's preferences will be taken into consideration for all aspects of care and honored to the extent practicable.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

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F-Tag F0554

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0554 during a standard health inspection conducted on 2025-09-17.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Allow residents to self-administer drugs if determined clinically appropriate.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0578

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-09-17.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0644

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0644 during a standard health inspection conducted on 2025-09-17.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0656

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-09-17.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0742

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0742 during a standard health inspection conducted on 2025-09-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0756

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-09-17.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-21.

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F-Tag F0912

Environmental Deficiencies
Harm Level: Potential for Minimal Harm

Federal health inspectors cited The Villa at the Park in Highland Park, MI for a deficiency under regulatory tag F-F0912 during a standard health inspection conducted on 2025-09-17.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Villa at the Park.

Correction Status: Deficient, Provider has no plan of correction.

📋 Inspection Summary

The Villa at the Park in Highland Park, MI inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Highland Park, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Villa at the Park or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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