Villa at Green Lake Estates: Missed Lab Order - MI
Six days passed. The tests were never collected. The resident fell at the facility on August 24 and was transferred to a hospital.
It was only after that transfer, while reviewing the electronic medical record, that staff at The Villa noticed the lab work had never been done.
The physician's order from August 18 covered four tests: a urinalysis with culture and sensitivity to check for a urinary tract infection, a complete blood count, and a BNP, which screens for heart failure. Any one of those results could have changed what caregivers knew about what was happening inside this resident's body during the six days between the order and the fall. None of them were ever drawn.
An interdisciplinary team note from August 20, two days after the order was placed, recorded that there were "no new orders, no new labs." The original lab order sat unfulfilled in the chart. The note did not flag the gap.
A complaint to the state agency prompted the inspection. The complainant, reached by phone on October 3, confirmed the account. The resident's guardian was a family member.
When inspectors interviewed the Director of Nursing on October 8, she acknowledged the failure directly. The facility, she said, "missed to draw the lab as ordered" and had identified its own non-compliance only after the resident had already been sent to the hospital. By then, the window for those results to guide care at the facility had closed.
The facility's own lab protocol, last revised in March 2014, lays out the sequence plainly: the physician orders the test, staff processes the requisition and arranges for collection, and the laboratory reports results back to the facility. The system broke at the second step and stayed broken for six days without anyone catching it.
After discovering the lapse on August 24, the facility moved quickly on paper. An ad-hoc quality assurance meeting was held the same day. The facility set a compliance date of August 25. Inspectors reviewing the record during the October survey found the facility had completed what is called a Past Non-Compliance process, a formal acknowledgment that the violation occurred within a defined window, that the facility caught it internally, and that corrective steps were taken before inspectors arrived.
That designation matters for how the citation is classified. Because the facility identified the problem, convened a meeting, and demonstrated ongoing audits by the time of the survey, inspectors cited the lapse as past non-compliance rather than an active deficiency. The level of harm was recorded as minimal harm or potential for actual harm.
What the record does not contain is any documentation of what, if anything, the missed labs meant for this resident's health between August 18 and August 24. Whether the UTI screen would have returned positive, whether the BNP would have flagged something concerning, whether earlier results would have changed the care this resident received before the fall — none of that is in the inspection report. The tests were never run. The results do not exist.
The resident came to The Villa to recover from a broken ankle. They had a guardian looking out for them. They had a doctor paying enough attention to order diagnostic tests within days of admission. What they did not have was a staff that processed those orders.
By the time anyone at the facility looked closely enough at the chart to notice, the resident was already in a hospital bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Green Lake Estates from 2025-10-08 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
The Villa at Green Lake Estates in Orchard Lake, MI was cited for violations during a health inspection on October 8, 2025.
The tests were never collected.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.