The Villa at Silverbell Estates

Inspectors wroteThis citation pertains to intake: 3006638. Based on interviews and record reviews the facility failed to ensure consistent and appropriate wound management by not completing an admission Braden assessment, not ensuring the timely implementation of wound treatments as ordered by the wound clinician, failing to consistently provide prescribed wound care treatments, failing to timely identify and report to the Physician of the worsening of the wound, and failing to complete labs as directed by the Physician for one (R404) of one resident reviewed for pressure wounds, which resulted in a change of condition and required prolonged hospitalization.

Inspectors wroteThis citation pertains to intake: 3006638. Based on interview and record reviews the facility failed to acknowledge, investigate and follow up on concerns reported by the family of one R404 of one resident reviewed for grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/04/2026 at 8:45 AM on a kitchen tour with Dietary Manager (DM) S observed the walk-in freezer with frozen condensate build up on shelving and floor. Also observed the interior of the walk-in cooler door damaged with the surface material pulling away from the door creating an exposed sharp edge and the surface is no longer smooth and cleanable. When queried during these observations, DM S said that repair requests have been entered in the electronic maintenance tracking system for both issues. On 05/04/2026 at 9:50 AM observed Pinegrove dining room ice machine drain tray full of water and overflowing onto the floor surface. [...]

Inspectors wroteBased on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain general repair and safe conditions of the premises. This resulted in an increased potential for safety concerns and contamination and a possible decrease in satisfaction of living (including for residents R40 and R87). Findings Include: R87 On 5/3/26 at approximately 9:37 AM, R87 was observed lying in bed. An extension cord that was covered with plastic was plugged into the wall and ran across the resident bed. The resident reported that they use the extension cord to charge their cell phone. On 5/5/26 at approximately 1:16 PM, the extension cord was still plugged into the wall and lying on the resident's bed. R40 On 5/3/26 at approximately 9:53 AM, R40 was observed lying in bed. They had an extension cord plugged into the wall and their cell phone was attached to the cord that ran across their bed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure irregularities identified by consultant pharmacist were addressed and noted in the resident's electronic record for five (R4, R6, R8, R11 and R36) of five residents reviewed for monthly medication regimen reviews (MRR). Findings Include:R6 A review of R6's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, schizophrenia, and post-traumatic stress disorder Continued review of R6's clinical record revealed the following MRRs notes dated: 3/29/26, 2/24/26, 10/28/25, 9/10/25, and 8/24/25 documented See reports for comment. There was no documentation available in the resident's clinical record of what the reports documented and/or the physician response to the pharmacy recommendations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriately stored in a safe/sanitary manner in one of two medication carts, and one of one treatment cart reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for three (R8, R47, and R93) of three residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently identify targeted symptoms and implement non-pharmacological interventions to manage impulsive and anxious behavior prior to the administration of multiple PRN (as-needed) anti-anxiety medication for one (R5) of one resident reviewed for chemical restraints, resulting in the resident being chemically restrained for staff convenience 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 develop an individualized care plan to address a resident's use of psychotropic medication and specific targeted behaviors, and non-pharmacological interventions for one (R5) of 18 residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) and engage gown and glove use during high contact resident care for wound care dressing changes for one (R72) of one reviewed for Enhanced Barrier Precautions.

Inspectors wroteThis citation pertains to intake #2737537. Based on interview and record review, the facility failed to honor an advanced directive for one resident (R902) of one resident reviewed for code status/advanced directives, resulting in five rounds of CRP/chest compressions (Cardiopulmonary Resuscitation) being performed against their wishes and subsequent emergency transfer to an acute care hospital.

Inspectors wroteThis Citation pertains to Intake #2685189Based on observation, interview and record review the facility failed to ensure a safe transfer via a Hoyer lift for one (R701) out of two residents reviewed for falls, resulting in R701 sustaining a fracture to the right femur that required surgery and an extensive hospital stay.

Inspectors wroteThis citation pertains to Complaint #2582127. Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator/Abuse Coordinator within the required timeframe for one (R801) of two residents reviewed for abuse.

Inspectors wroteThis citation pertains to Complaint #2582127. Based on observation, interview, and record review, the facility failed to adequately assess the resident's skin and conduct a thorough assessment for a potential change in condition for one (R801) of two residents reviewed for abuse.

Inspectors wroteR80 Record review revealed R80 was a long-term resident of the facility, originally admitted on [DATE]. R80 had a recent hospitalization and they were readmitted back to the facility on 3/18/25. R80's admitting diagnoses included pneumonia, congestive heart failure, chronic kidney disease, major depressive disorder, and gout. Based on Minimum Data Set (MDS) assessment dated [DATE], R80 had a Brief Interview for Mental Status (BIMS) score 9/15, indicative of moderate cognitive impairment. R80 had a guardian (daughter) who was making decisions on their behalf. An initial observation was completed on 6/17/25 at approximately 10:20 AM, R80 was observed in their bed with a brief. They had their eyes closed but opened their eyes when called upon but did not answer to any questions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall with major injury for one Resident (R47) of two residents reviewed for falls. This resulted in actual harm for R47, who sustained a left ankle fracture, and a subsequent infection.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate staffing to meet the care needs of the residents, with the potential to affect all residents (including R10 and R85).

Inspectors wroteOn 6/16/25 at approximately 9:07 AM, a refrigerator located in the large resident dining room was observed. A piece of paper was taped on the door that read: Resident Fridge Only ensure food is labeled and dated. Upon opening the refrigerator, the following medications were observed in the bottom drawer: Semglee (insulin), Lantus (insulin x2), TPN (Total Parenteral Nutrition x2 bags), Thiamine (Vitamin B1 x2), Infuvite (multivitamin x2) and SMOFLipid (lipid injectable used in parenteral nutrition x2). On 6/16/25 at approximately 10:34 AM, an observation and interview were conducted with the Director of Nursing (DON). The DON was queried as to why resident's medications were stored in the Resident Fridge (Only). The DON reported that the fridge located in the storage room was not working and a new fridge was ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a resident for two (R53 and R78) of four residents reviewed for abuse, resulting in R53 and R78 verbally abusing and intimidating each other on multiple occasions leading to R53 punching R78 in the stomach and on a different occasion, R78 hitting R53 in the face.

Inspectors wroteBased on interview and record review, the facility failed to report allegations/incidents of resident-to-resident physical and verbal abuse to the State Agency (SA) for two residents (R53 and R78) out of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate allegations of abuse and actual abuse for two (R53 and R78) and potential unidentified residents out of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received routine nail care for one (R34) out of two residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteR78 On 6/16/25 at 9:25 AM, R78 was observed standing in their room. R78 was asked if he had any concerns at the facility. R78 explained he would walk around the whole facility for exercise . had clocked it so he knew how many miles he walked a day . there was another resident, he only knew their first name, that would always flip his middle finger at him every time he walked past . one day he was walking and this resident had his wheelchair in the doorway of his room . he ignored him when he went past . the next time around this resident was all the way in the hall . he thought he wanted to talk to him so he stopped and asked what he wanted . the resident flipped him the middle finger, so he grabbed his finger . the resident hit him in the stomach, so he pushed his index fingers in his eyes . the nurses came and were yelling at us . he put his hands up and stepped away from the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed and failed to notify the physician/provider timely on abnormal lab results for one resident (R80) of one resident reviewed for diagnostics, resulting in the potential for decline in health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a urinary catheter drainage bag (s) (leg bag and bedside/night bags) in a sanitary manner for one of one sampled resident (R44) reviewed for infection control with urinary catheter with potential for contamination and spread of disease to a vulnerable population. Findings Include: Record review revealed R44 was long term resident admitted to the facility on [DATE]. R44's admitting diagnoses included myelopathy, bipolar disorder, and neuro muscular dysfunction of the bladder. Based on the Minimum Data Set (MDS) assessment dated [DATE], R44 had a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. R44 had a urinary catheter due to their medical condition. R44 needed some level of staff assistance to complete their lower body dressing and toileting hygiene tasks. [...]

Inspectors wroteThis citation pertains to Intake #MI00147108 Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available per physician orders and maintain accurate documentation of controlled substances for one (R601) of three residents reviewed for medications.

Inspectors wroteThis Citation Pertains to Intake #: MI00145908 Based on observation and interview, the facility failed to store tracheostomy supplies in a clean and sanitary condition for one (R903) of one Resident reviewed for infection control resulting in the potential to cause an infection(s) for a compromised resident with multiple comorbidities.

Inspectors wroteThis citation pertains to intake #MI00145455. Based on observation, interview and record review, the facility failed to ensure that a portable oxygen tank was properly secured while left unattended resulting in the potential for the tank to be knocked over, causing a potential rocketing of the cylinder and injury to all residents in the immediate area, of a total census of 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared served, and stored in a sanitary manner for one resident (R32) of one resident reviewed for food storage. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for seven residents (R#s 5, 42, 66, 13, 7, 55, and 289) of seven residents reviewed for dignity.

Inspectors wroteThis citation pertains to intake#MI00144094. Based on interview and record review, the facility failed to ensure sufficient nursing staff were provided to meet resident needs for three residents (R58) and two other residents (who preferred to remain anonymous), potentially affecting all 87 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three insulin pens were stored in the appropriate place and two of four medication carts observed unlocked.

Inspectors wroteOn 5/6/24 at 12:20 PM, residents were observed in the dining room, being served soup from a soup kettle. The internal temperature of the soup inside the kettle was measured to be 117 degrees Fahrenheit. On 5/6/24 at 12:25 PM, when queried, Dietary Manager K looked at the kettle and stated the temperature dial needed to be adjusted to a higher temperature. According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57 ºC (135ºF) or above . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences for seven residents (R#'s 66, 35, 70, 41, 68, and 65) of 12 residents reviewed for food preferences, resulting in verbalized complaints and dissatisfaction with meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately implement enhanced barrier precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and wear the required personal protective equipment (PPE) for resident's on EBP for four residents, (R#'s 64, 45, 49, and 33) of seven residents reviewed for transmission based precautions, resulting in the potential for the transmission of multidrug-resistant organisms.

Inspectors wroteBased on interview, and record review, the facility failed to coordinate a transfer to the hospital per the resident's choice for one resident, (R35) of two residents reviewed for choices, resulting in R35 feeling the facility did not take their health condition seriously.

Inspectors wroteBased on interview and record review the facility failed to ensure correct and completed involuntary discharge transfer documents for one resident of one resident reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure X-rays were ordered in a timely manner after a fall for one resident (R32) of one resident reviewed for diagnostic testing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate vision care was provided for one resident (R21) of one resident reviewed for vision/hearing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Physician's orders were followed for oxygen therapy administration for two residents (R58 and R63) of two residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management services for two of two residents (Resident 84 and 290 ) reviewed for pain, resulting in unrelieved pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate of less than five percent when three medication errors were observed and one medication not signed out from a total of 25 opportunities observed during medication administration, resulting in a medication error rate of 12%.

Inspectors wroteBased on interview and record review, the facility failed to ensure pertinent resident information was documented in the medical record for one resident (R24) of one resident reviewed for Social Services/Guardianship resulting in the potential for clinical misrepresentation of the resident and errors in providing a continuum of care.

Inspectors wroteThis citation pertains to intake(s): MI00140190 & MI00140245. Based on interview and record review the facility failed to ensure accurate wound assessments, timely implementation of treatment for identified wounds, coordination of care and wound services and ensure a collaborative approach for wound healing was completed with the dietician for two (R's 501 & 506) of three residents reviewed for pressure wounds, resulting in R506 to have developed an infected unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) buttocks/sacral wound (after debridement identified as a Stage III- full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissues and rolled wound edges are often present- buttock/sacral wound) that required the [...]

Inspectors wroteThis citation pertains to Intake Number(s): MI00138031, MI00138863, MI00140340, and MI00141846. Based on observation, interview, and record review, the facility failed to document administration of schedule II (2) controlled substances (drugs that have high potential for abuse and/or addiction) according to professional standards of practice for nine (R502, R504, R509, R511, R512, R513, R514, R515, and R516) of 12 residents reviewed for medications.

Inspectors wroteDeficient Practice #1 This citation pertains to Intake Number(s): MI00138031, MI00138863, MI00140340, and MI00141846. Based on observation, interview, and record review, the facility failed to ensure schedule II (2) controlled substances (drugs that have high potential for abuse and/or addiction) were accurately reconciled, administered, and documented; and discrepancies in counts were addressed for eight (R502, R509, R511, R512, R513, R514, R515, and R516) of 12 residents reviewed for medications.

Inspectors wroteBased on interview and record review the facility failed to promptly report abnormal x-ray results to the physician/physician extender for one (R501) of four residents reviewed for change in condition.