Vista Grande Villa
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
fired on 09/15/25 but wasn't sure why. CNA E then stated she did work 9/07/25 and they were very short staffed and that Resident R1 must have her confused with a different CNA. On 09/24/25 at 2:21pm during an
interview with CNA G, it was reported that she was assigned to Resident R1 on 09/08/25 and Resident R1 was tearful and didn't want help with anything but thanked CNA G for being kind. CNA G stated she could tell something was wrong and upon probing Resident R1 became tearful and told her CNA E she was scared because the day
before CNA E was mean and told her she could and should be doing things for herself. CNA G stated Resident R4 chimed in stating CNA E was a mean. 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 Resident R1.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Grande Villa
2251 Springport Road Jackson, MI 49202
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake #2624374Based on observation, interview and record review the facility failed to develop and implement a plan of care related to deep tissue injury for one resident (#2) of two reviewed for skin care plans. Review of the clinical record revealed Resident 2 (Resident R2) was admitted to the facility on [DATE REDACTED] for short term rehabilitation after a fall at home that resulted in a pelvic fracture. Review of Resident R2's skin assessment dated [DATE REDACTED] revealed Resident 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. Resident 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 Resident R2 was alert and oriented x 4. Resident R2's Minimum Data Set had not yet been completed. On 09/24/25 at 9:39 am, during a bedside interview, Resident R2 was observed resting in her recliner, Resident 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 Resident R2 reported the nurses put some sort of cream on it daily. Resident R2 reported being significantly less mobile since the fall with fracture and was at the facility for short term therapy. Resident R2 reported pain with movement and repositioning. Review of Resident R2's care plans revealed that there was no care plan in place regarding Resident R2's DTI. There were no interventions for prevention of further skin breakdown, nor were there any interventions for treatment to promote healing of Resident 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 Resident R2's sacrum it was not opened. RN C stated Resident R2 received a foam dressing to the sacrum, had a specialty bed, was provided a cushion, and should be repositioned frequently. RN C stated Resident R2 can reposition self but would cause shearing and should be helped by staff for repositioning. Review of Resident 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.
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Vista Grande Villa in Jackson, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 Jackson, 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 Vista Grande Villa or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.