The Villa at Green Lake Estates

Inspectors wroteThis citation pertains to intake #2714636 Based on interview and record review, the facility failed to report an allegation of abuse/neglect for one resident (R906) of two residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation pertains to intake 3013247Based on observation, interview and record review the facility failed to provide appropriate catheter care for one resident (R913), of two residents reviewed for catheters.

Inspectors wroteThis citation pertains to Intake Number: 2714799 Based on interview and record review, the facility failed to ensure a physician's order was in place for an abdominal binder and implement effective interventions to prevent dislodgement of a feeding tube for one (R907) of one resident reviewed for tube feeding, resulting in a hospital transfer to reinsert the feeding tube.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision with a safe environment for one (R900) of four Residents reviewed for falls/accident hazards, who was identified as high fall risk (history of fall with injury), wanderer, with severe cognitive impairment resulting in multiple falls on the staircase or with the step of the staircase, and multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain (using the reasonable person concept).

Inspectors wroteThis citation pertains to intake # 2615985 Based on interview, and record review, the facility failed to obtain laboratory services ordered by the physician/practitioner for one (R901) of two Residents reviewed for laboratory services.

Inspectors wroteThis citation pertains to complaint: 2600725. Based on observation, interview and record review the facility staff failed to follow the facility policy regarding the implementation of individualized interventions for skin protection for one (R105) of three residents reviewed for pressure wounds.

Inspectors wroteThis citation pertains to complaint: 2600725. Based on interviews and record reviews the facility failed to ensure adequate supervision and/or resident specific interventions to prevent falls for one (R103- a resident with a known history of falls with injury, developmental delay, non-compliance with care, impulsive & combativeness) of two residents reviewed for falls, resulting in injuries that required the resident to be transferred to the hospital for a higher level of care.

Inspectors wroteR37 On 6/30/25 at 10:15 AM, R37 was observed lying in bed. R37 reported he was not feeling well at that moment and was going to the hospital. When queried about the care in the facility, R37 reported he wore a Life Vest (a wearable cardioverter defibrillator vest that continuously monitors for life-threatening irregular heart rhythms and automatically delivers shock treatment to save a person's life, if needed). R37 reported the vest was not removed because he was to wear it at all times. R37 reported the vest did not fit properly and was very tight which caused a big wound on the trunk of his body where the vest made contact with his skin. R37 reported the facility ordered a new vest, but he never received it. R37 reported the wound was painful and uncomfortable. [...]

Inspectors wroteBased on observation and interviews, the facility failed to properly date (Insulin) and appropriately store medications in one out of four medication carts resulting in the potential for harm due to unsafe medication administration and decreased efficiency.

Inspectors wroteBased on interview and record review the facility failed to ensure coordinated hospice service visits for one resident (R9), of one resident reviewed for end of life care, resulting in the potential for unmet end of life care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms for 26 of 42 resident rooms (#'s: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, and 213, ), resulting in the potential for inadequate space and resident dissatisfaction. Findings Include: On 7/1/25 at approximately 11 AM, a review of the facility bed count information sheets and observations of Medicare/Medicaid resident rooms measurements provided by the facility administrator revealed the following: ROOM# SQ. FT. # OF BEDS 101 149.46 2 102 148.4 2 103 148.4 2 104 148.4 2 105 148.4 2 106 148.4 2 107 148.4 2 108 148.4 2 109 148.4 2 110 149.46 2 111 149.46 2 112 149.46 2 113 149.46 2 201 149.46 2 202 148.4 2 203 148.4 2 204 148.4 2 205 148.4 2 206 148.4 2 207 148.4 2 208 148. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure treatment in a dignified manner for two residents (R#'s 17 and 70) of two residents reviewed for dignity, resulting in the potential for embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective grievance resolution process to ensure prompt resolution of resident concerns for one (R56) of one resident reviewed for grievances, and seven of eight residents who wished to remain anonymous who attend the resident council interview.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report injuries of unknown origin to the Administrator/Abuse Coordinator for one (R38) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to develop an integrated hospice care plan for one resident (R9) of one resident reviewed for hospice services resulting in the potential for unmet end of life care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dressing changes were completed as documented for one (R55) of two residents reviewed for Skin Conditions.

Inspectors wroteThis citation pertains to Intake Number: MI00151566 Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent accidents and failed to assess and determine the root cause of a fall for three (R13, R38, and R72) of six residents reviewed for accidents and supervision, resulting in R13 eloping from the facility, R38 repeatedly entering other residents' rooms and the potential for avoidable accidents.

Inspectors wroteThis citation pertains to intake #MI00150133 Based on interview and record review the facility failed to ensure a stop date for antibiotic treatment for one resident (R#306) of three residents reviewed for antibiotic stewardship resulting in the resident receiving numerous additional doses of antibiotic medication.

Inspectors wroteThis citation pertains to intake #MI00150928 Based on interview and record review, the facility failed to ensure freedom from misappropriation for one resident, (R302) of two residents reviewed for misappropriation, resulting in a staff member stealing R302's money.

Inspectors wroteThis citation pertains to intake #MI00150133. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to transmission based precautions (TBP) for two residents (R#'s 300 and 307) of six residents reviewed for infection control.

Inspectors wroteThis citation pertains to Intake #MI00149522. Based on observation, interview, and record review, the facility failed to prevent a fall with injury for one Resident (R701) of three residents reviewed for falls and accidents, resulting in actual harm, when R701 required stitches to their shoulder after falling out of bed.

Inspectors wroteThis citation pertains to intake #: MI00147691, MI00147358 Based on observation, interviews and record review facility failed implement an effective discharge planning process for two (R901 and R902) of two residents reviewed for transfer/discharge, resulting in psychosocial harm using the reasonable person concept for R901 who has aphasia (difficulty communicating due to damage in the brain), a language barrier, and severe cognitive impairment, was discharged to another facility, farther away from family, without approval from the resident's representative and without notification to the other facility; and R902 feeling frustrated and dissatisfied with their living situation.

Inspectors wroteThis citation pertains to Intake # MI00147358 Based on interview and record review, the facility failed to provide written transfer notification to the resident's representative including reason, effective dates, and the location to which the resident was being transferred and Ombudsman notification for one Resident (R901) of two residents reviewed for transfers/discharge out of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled substance medications were documented per facility policy and professional standards on the Medication Monitoring/Control Record and Medication Administration Record for two residents (R#'s 704 and 705) of three residents reviewed for professional standards, resulting in the potential for loss of accountability for controlled substances.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate storage of medication and treatment supplies in two of five medication carts. This deficient practice had the potential to affect multiple residents residing in the facility.

Inspectors wroteThis citation pertains to intake MI00144470 Based on interview and record review, the facility failed to provide reasonable accommodation of resident needs by not promptly responding to the call lights for three residents (R800, R801, R802) of three residents interviewed resulting in the residents contacting the facilities receptionist to assist in contacting nursing staff. A complaint was received by the State Agency on 5/11/24 alleging a resident was observed requesting assistance from nursing staff for the duration of their visit (approximated time of 45 minutes to one hour) resulting in the visitor involving assistance from the facility receptionist. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that resident rights to private and confidential mail delivery was maintained for all residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents and visitors had access to previous survey results, resulting in residents and visitors being uninformed of deficiencies identified in the facility. This had the potential to affect all residents who resided in the facility.

Inspectors wroteThis citation pertains to intake #MI00143647. Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for residents that participate in the resident council.

Inspectors wroteR56 On 5/6/24 at 9:57 AM, R56 was observed sitting up in a wheelchair. R56 reported only receiving 2 showers since their admission (on 4/11/2024) and expressed displeasure related to missing scheduled showers. Review of the clinical record revealed R56 was admitted to the facility on [DATE] with diagnoses that included: muscle weakness and polyarthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R56 scored 15/15 (which indicated intact cognition). On 5/8/24 at 12:31 PM, DON was queried regarding their current process for documenting resident showers. The DON reported that resident showers should be documented in the electronic health record but they are also documented on paper (shower sheets). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment was free from accident hazards regarding storage of sharps (blood sugar testing lancets) in one of four medication carts reviewed for medication storage. This has the potential to affect multiple residents on the first floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a system in place prior to installing assist bars/rails to ensure appropriate consent, assessment, and physician orders were completed with ongoing monitoring and assessment for eight (R32, R42, R9, R14, R21, R25, R26, R57, and R74) resulting in the potential for inappropriate use and or injury from the device. This deficient practice has the potential to affect all 76 residents of the facility.

Inspectors wroteThis citation pertains to intake #MI00141921. Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided for the residents that resided on the first floor (including R72 and multiple residents from the confidential resident council meeting), resulting in delayed medication administration and increased potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices with regards to Enhanced Barrier Precautions (EBP), and linen storage for eight of eight residents (R34,R21,R62,R57,R33,R74,R55 and R29) reveiwed for EBP.

Inspectors wroteThis citation pertains to Intake MI00143647 Based on observation, interview and record review, the facility failed to treat a resident with dignity and respect for one (R73) of five resident reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R12) was assessed for safe self-administration of medication of one resident reviewed for self-administration, with potential for inappropriate administration of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, with a confirmed history of physical abuse, was not threatened to change rooms for staff convenience for one (R73) of one resident reviewed for room change.

Inspectors wroteThis citation pertains to intake #MI00141921. Based on interview, and record review, the facility failed to ensure medications were administered and/or the physician was notified of the late administration according to professional standards of practice for one (R72) of one resident reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently implement interventions to prevent the development of a new pressure ulcer and/or worsening of one facility acquired pressure ulcer for one resident (R42) and failed to ensure skin assessments were completed for one (R9) of three residents reviewed for pressure ulcer prevention and management.

Inspectors wroteThis citation pertains to Intake MI00144347 Based on observation, interview and record review, the facility failed to ensure complete and accurate documentation of intermittent (straight) catherization for one (R74) of two residents reviewed for catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident prescribed psychotropic medication (Antipsychotic/AP) had adequate indication for use, appropriate consent to receive the medication, clinical rationale to support continued use in absence of mood/behavior symptoms, as well as identify and monitor resident specific behaviors and approaches for one (R179) of five residents reviewed for unnecessary medication, resulting in unnecessary use of psychotropic medication and the inability to monitor the effectiveness of the prescribed treatment due to lack of supporting documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms for 26 of 42 resident rooms (#'s: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, and 213, ), resulting in the potential for inadequate space. Findings Include: On 5/6/24 at 2:30 p.m , a review of the facility bed count information sheets and observations of Medicare/Medicaid resident rooms revealed the following: ROOM# SQ. FT. [...]

Inspectors wroteThis citation pertains to intake: MI00141154. Based on observations, interviews, and record reviews the facility failed to ensure a Licensed Practical Nurse (LPN) H Immediately responded to a reported change of condition for R402 who was reported to the nurse as unresponsive, resulting in delayed follow up care, delayed initiation of Cardio Pulmonary Resuscitation (CPR), delayed summoning of Emergency Medical Services and death, for one (R402) of one resident reviewed for CPR.

Inspectors wroteThis citation pertains to intake: MI00141154. Based on interviews and record reviews the facility failed to ensure facility staff consistently ensured residents were treated in a dignified manner for one (R403) of two residents reviewed for abuse/negligence, resulting in the resident to have felt disrespected.

Inspectors wroteThis citation pertains to intake: MI00141154. Based on interview and record review the facility failed to report an allegation of neglect to the State Agency (SA) for one (R402) of one resident reviewed for Cardio Pulmonary Resuscitation (CPR).

Inspectors wroteThis citation pertains to intake: MI00139836. Based on interviews and record reviews the facility failed to ensure physician orders were transcribed and implemented as ordered by the Physician Assistant, ensure abnormal laboratory results were reported to the physician, ensure an EKG and echocardiogram was completed as ordered by the physician, and ensure the appropriate mode of transportation services were activated to transport the resident to the hospital for one (R909) of one resident reviewed for a change of condition, which resulted in the delay of care including the administration of antibiotics, treatment and medical services and required the resident to be transferred and admitted to the hospital for a higher level of care.

Inspectors wroteBased on interview and record review the facility failed to timely assess, monitor and follow physician orders for one R72 of one resident reviewed for hospitalization resulting in a decrease in R72's condition (sepsis) and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timely accurate advanced directive/code status was in place for two residents (R226 and R68) out of three residents reviewed for Advanced Directives.

Inspectors wroteBased on interview and record review the facility failed to ensure professional Nursing standards were appropriately practiced for three residents ( R14, R24 and R58) of three residents reviewed for standards of practice.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate skin assessments, and treatments for pressure ulcers were ordered and completed per physician's orders for two residents (R#'s 71 and 226) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was transferred into a transportation vehicle in a safe manner for one resident (R74) out of three residents reviewed for accidents, resulting in R74 hitting their head on the top latch of the transportation/van vehicle causing excessive bleeding, a trip to the emergency department, and a diagnosis of minor closed head injury.

Inspectors wroteBased on interview and record review the facility failed to ensure a legally authorized representative signed a binding arbitration agreement (a legal contract that dictates an out-of-court alternate form of dispute resolution) for one resident (R8) of three residents reviewed for binding arbitration agreements.