The Villa At Parkridge
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # 2589332.Based on interview and record review the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for one Resident (#3) of three reviewed.Findings include:Review of the clinical record revealed Resident 3 (Resident R3) was admitted to the facility
on [DATE REDACTED] and transferred to the hospital on 8/6/20 where a fractured right hip was discovered. Further
review of the clinical record scored 13 out of 15 on the Brief Interview for Mental Status. There was no documentation in the clinical record on 8/5/26 that indicated Resident R3 had a fall. A late entry nursing progress note dated 8/07/25 revealed that on 8/5/25 Resident R3 was observed sitting next to his bed and Resident R3 was unable to articulate what happened. Licensed Practical Nurse (LPN) N and Certified Nursing Assistant (CNA) O placed Resident R3 back to bed. LPN N documented Resident R3 had no injuries, no pain and that a body assessment was conducted. There was no notation that Resident R3's physician or Responsible party had been notified on 8/05/25 of
the incident. Further review of the clinical record there was no documentation that range of motion to any extremities was assessed, no documentation regarding neuroglial checks. Review of Occupational Therapy Notes dated 8/06/25 revealed Resident R3 was complaining of right hip and told the therapist that he fell the day before. Therapy had notified nursing. Nursing note dated 8/06/25 reflected nursing was notified by therapy that Resident R3 reported he fell the day prior and had complaints of right hip pain. Resident R3 guardian came to visit on 8/6/25 and was notified about Resident R3's fall from Resident R3's roommate. Resident R3's guardian went to talk to Administration and requested Resident R3 to be sent to the hospital immediately. Review of Resident R3 fall investigation which included hospital records, revealed Resident R3 sustained a right hip fracture that required surgical repair. On 8/20/25 at 9:25 am during an interview with Assistant Director of Nursing (ADON) C she reported nobody was aware that Resident R3 fell until Therapy had notified her. LPN N was aware but forgot to document it and pass the information along. When queried why the Physician and Responsible party wasn't notified until the day after the fall, ADON C stated they had just found out and had not had a chance to contact them before Resident R3's roommate told the Responsible party/guardian. On 8/20/25 at 12:01pm during a phone interview with LPN N she reported she observed Resident R3 on the floor on his right side about 4:00pm on 8/05/2025. LPN N stated she helped Resident R3 into bed and thought Resident R3 was fine. When queried about assessment, LPN N stated Resident R3 denied pain and neuro checks were initiated but wasn't sure if they were documented, LPN N also stated a body check was done and was ok when asked to elaborate about a body check, LPN N stated she looked over Resident R3's body for cuts. abrasions, bruises. When queried if any type of range of motion had been done LPN N stated no. When queried why she did not notify Resident R3's physician and Responsible party/guardian, LPN N stated didn't have a reason, she just didn't. On 8/20/25 at 11:50am during an interview with the Director of Nursing (DON) B she reported the expectation was that after a fall or any type of incident once the resident was fully assessed and safe the physician and responsible party were to be notified.
Residents Affected - Few
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:
The Villa at Parkridge in Ypsilanti, 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 Ypsilanti, 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 Parkridge or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.