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Villa at Green Lake Estates: Missed Lab Order - MI
The tests were never collected....
Latest reports, citations, and penalties from CMS data
The tests were never collected....
The inspection, completed October 8, 2025, found the facility failed to provide timely pain medication to a resident on hospice care who was dying....
The elopement came to light not because anyone saw R2 leave, but because staff did a head count and he was gone....
A progress note from the former administrator, dated September 11, documented that R25's power of attorney was called that day to discuss the move....
That was the morning of October 10, when state inspectors were present....
The deficiency covered every resident investigated, two out of two....
The incident at Taylorville Care Center was reported to state regulators and triggered a federal inspection completed October 9, 2025....
She died approximately one week later....
The surveyor walked the 400-wing spa room on the morning of October 2nd....
The plastic display holder near the front desk held a form dated September 10....
None of that happened the way it was supposed to....
Federal inspectors arrived on October 8, 2025, following a complaint filed nine days earlier....
The resident, identified in inspection records only as R2, experienced a change in condition at 1:15 p.m....
The inspection, conducted September 26, 2025, was a complaint visit to the 74-resident facility at 600 24th Avenue Southwest....
Resident P told inspectors he waited as long as nine hours after requesting pain medication....
What inspectors documented during the October 14 complaint inspection suggested that commitment existed more on paper than in practice....
for a resident identified in the report as Resident 70, read like a routine clinical assessment....
Inspectors observed the nurse, identified in the report as RN #1, at 8:28 a.m....
Inspectors noted the resident had bruising in several areas, which the facility's director of nursing attributed at least in part to anticoagulant therapy....
After inspectors made their findings, the Director of Nursing and Administrator consulted with the facility's Medical Director....