The Villa At Green Lake Estates
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm
Nursing (DON) was asked whose responsibility it was to implement the wound and skin management interventions and the DON replied the nurses. When asked about Resident R105 current condition to have multiple identified wounds, compared to the lack of care plans and interventions implemented despite the guidance of the facility's policy, the DON stated they would review Resident R105's care plans and follow back up. No further explanation or documentation was provided by the end of the survey.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villa at Green Lake Estates
6470 Alden Dr Orchard Lake, MI 48324
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
of care and lack of interventions implemented for adequate supervision and resident specific interventions to ensure the safety of Resident R103. The DON stated staff was told verbally to increase monitoring of the resident.
When asked what increased monitoring meant for Resident R103, considering the other residents in the facility were rounded on every two hours (per the DON), the DON did not have a response. The DON stated there was a lot of traffic walking by Resident R103's room, considering where Resident R103's room was located. The DON was asked if that was considering all shifts, especially on the evening and nights when less staff are in the building and
the DON did not have a response. The DON was asked if the facility staff had completed an investigation for the fall and asked the root cause identified. The DON replied they had completed an investigation. The DON was asked to provide the investigation for review. A review of the investigation provided by the DON documented in part . Resident admitted with severe intellectual disability and developmental disorder of speech and language. BIMS (brief interview for mental status) score 0 (which indicated severely impaired cognition). Between approximately 7:15 pm and 7:30 pm, during a brief change in the shower room, the resident's daytime CNA (certified nursing assistant) requested assistance from the on-coming CNA due to
the resident's history of combative behavior. The resident declined to use the grab bar for stability. The additional CNA provided assistance, and the brief change was completed with out incident. The resident was then assisted back to his room and helped into bed, with the call light placed within reach. At approximately 9:00 pm, a CNA entered the resident's room to take vitals and discovered the resident on the floor, lying on his left side in the prone position. Fall occurred unwitnessed, despite interventions earlier in
the evening. Modified Interventions to the Plan of Care. Reinforce use of safety interventions (grab bar, two-person assist as needed). Fall prevention strategies reinforced with staff, including placement of call light and increased observation during evening hours (none of which were documented on the residents care plans). Summary of Factual Investigative Findings. At approximately 9:00 . The resident was discovered on the floor by staff during routine vitals checks. Post-fall assessment revealed injury, EMS was called, and the resident was transferred for hospital evaluation. No further explanation or documentation was provided by the end of the survey.
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The Villa at Green Lake Estates in Orchard Lake, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Orchard Lake, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Villa at Green Lake Estates or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.