The Villa At West Branch
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
up, CNA Q replied, Yeah, a bit. (Resident #701) was like moaning a flinching. When queried if they had taken care of Resident #701 recently prior to their passing, CNA Q verbalized they had but was unable to recall a specific date. CNA Q stated, (Resident #701) was a lot better than that. They were eating and was (getting) up. When (Resident #701) started not wanting to feed themselves, we knew they were declining.
CNA Q was asked if they recalled anything else and stated, 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.
When queried if Resident #701's skin felt hot when they touched them, CNA Q replied, Yes, very hot. CNA Q was asked if they informed the nurse and replied, Yeah. CNA Q then stated, It was the hospice nurse who said to take (Resident #701's) vitals.Review of facility policy/procedure entitled, Change in a Resident's Condition or Status (Revised: February 2021) revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an). d. significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times) . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of facility provided policy/procedure entitled, Hospice Program (Revised July 2017) revealed, Hospice services are available to residents at the end of life. 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care. c. Providing medical direction, nursing and clinical management of the terminal illness. e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: a. Twenty-four-hour room and board care; b.
Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; c. Notifying the hospice about the following: (1) A significant change
in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (4) The resident's death. d. 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.
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If continuation sheet
The Villa at West Branch in West Branch, 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 West Branch, 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 West Branch or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.