Vista Grande Villa
Vista Grande Villa in Jackson, MI — inspection on November 14, 2025.
Found 2 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
Review of the facility's Abuse, Neglect and Exploitation policy dated 11/15/23 page 6. defined Mental abuse Includes, but not limited to humiliation, harassments, threats of punishment or deprivation.
Page 7 of the abuse policy defined Physical abuse Includes, but is not limited to hitting, punching, slapping, biting and kicking. It also includes controlling behavior through corporal punishment.
Page 7. defined Verbal abuse as Means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.On 09/24/25 at 1:07 PM, during an interview with NHA A he offered no explanation for CNA E's behavior and stated CNA E was terminated on 09/15/25 for customer service issues related to R1.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Grande Villa
2251 Springport Road Jackson, MI 49202
SUMMARY STATEMENT OF DEFICIENCIES
Review of the clinical record revealed Resident 2 (R2) was admitted to the facility on [DATE] for short term rehabilitation after a fall at home that resulted in a pelvic fracture.
Review of R2's skin assessment dated [DATE] revealed R2 was admitted with a Deep Tissue Injury (DTI) on the sacrum that measured in length 0.6 centimeters, a width of 0.5 centimeters. R2 scored a 15 indicating she was at risk for skin breakdown on the Braden Scale dated 9/16/25.
Review of the nursing admission progress note reflected R2 was alert and oriented x 4. R2's Minimum Data Set had not yet been completed. On 09/24/25 at 9:39 am, during a bedside interview, R2 was observed resting in her recliner, R2 reported she fell at home on fractured her pelvis and sustained a bruise on her tailbone because of the fall.
When queried what was being done for the bruise R2 reported the nurses put some sort of cream on it daily. R2 reported being significantly less mobile since the fall with fracture and was at the facility for short term therapy. R2 reported pain with movement and repositioning.
Review of R2's care plans revealed that there was no care plan in place regarding R2's DTI.
There were no interventions for prevention of further skin breakdown, nor were there any interventions for treatment to promote healing of R2's DTI. On 09/24/25 at 1:55 pm, during an interview with the facility's Wound Nurse & Unit Manager /Registered Nurse (RN) C she reported being the facility's wound nurse and reported there was a DTI on R2's sacrum it was not opened. RN C stated R2 received a foam dressing to the sacrum, had a specialty bed, was provided a cushion, and should be repositioned frequently. RN C stated R2 can reposition self but would cause shearing and should be helped by staff for repositioning.
Review of R2's care plans was done with RN C who agreed there was nothing in place to promote the healing of the DTI or prevent further pressure ulcers from developing.
Facility ID: