Villa at Silverbell Estates: Bruising Ignored Hours - MI
The resident, identified in inspection records as R801, was eventually sent to the hospital at 2:30 AM. By then, a nurse had pulled back her gown and found bruising across her chest, her left breast, and a large lump near her shoulder. The resident, normally alert and responsive according to staff, was not responding to questions.
A second nursing assistant, identified as CNA 'I', told investigators she had seen bruising on R801's chest or arm the day before, on July 23, and said nothing to anyone.
The last vital signs on record before the hospital transfer were taken at 5:19 PM, the same afternoon shift when the bruising was first reported. No skin assessment had been completed for R801 between July 5 and July 30. The progress note written by the nurse that night documented only what the nursing assistant had told her, not the nurse's own physical findings. Nothing in the record captured the change in R801's mental status that multiple staff described to investigators.
The Director of Nursing said she was on vacation during the incident. She told inspectors that R801 was sent to the hospital for bruising and, in her view, did not have a change in condition. She said she expected nurses to assess for pain, and if a resident did not report pain, the nurse probably continued passing medications. She was not aware that no skin assessments had been completed for 25 days.
The Assistant Director of Nursing, who returned to work the day R801 was transferred, said a full assessment should have been completed and documented when staff first flagged the bruising. She had no explanation for why it wasn't.
The former administrator, not the current Director of Nursing, was the one who ultimately conducted the facility's internal investigation, the investigation that captured staff accounts of R801's altered mental state. The Director of Nursing said she was not working. The documentation gap remained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Silverbell Estates from 2025-09-03 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 22, 2026 · Our methodology
The Villa at Silverbell Estates in Orion, MI was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records as R801, was eventually sent to the hospital at 2:30 AM.
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.