The Villa At Green Lake Estates
The Villa at Green Lake Estates in Orchard Lake, MI — inspection on October 8, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
a pathological fracture (a broken bone that happens from an underlying disease with minimal or no trauma) from osteoporosis (weak bones).
The DON was asked, how did R900 obtain a pathological fracture from osteoporosis if the hospital paperwork, and the facility stated injuries were from the impact of a mechanical fall down the stairs (it must be noted that R900 did not have a diagnosis of osteoporosis in the EMR and they were not listed on hospital discharge summary).
The DON did not provide any further explanation.
The DON was asked how they planned to keep other ambulatory residents safe from the unsecured staircase located in the hallway on the second floor.
The DON reported that they usually did not have issues with residents in the staircase prior to this incident and now the team would work on a solution. On 10/7/25 at 1:54 PM, an interview with Nurse B was completed.
Nurse B confirmed that they were assigned to care for R900 and the fall incident on 10/3/25 happened during their shift.
They were asked about their documentation for the fall incident and their assessment/vitals.
Nurse B reported that they did everything for the incident, but they did not document what they did.On 10/7/25 several attempts were made to contact Nurse E via telephone with no answer or call back.On 10/7/25 at 3:07 PM), an observation was made of the actual staircase/stairwell in which R900 fell on.
The staircase was open for anyone to walk up or down the stairs.
There was nothing to deter those that were cognitively impaired and able to attempt to use the stairs.The IJ that began on 9/17/25 was removed on 10/8/25 when the facility took the following actions to remove the immediacy: Nurse management team reviewed all like residents and completed new fall risk assessments.The interdisciplinary team met and reviewed all new risk assessments and updated all current resident's plans of care accordingly.Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides on the second floor to impede resident usage.
Measurements for the stairwell have been taken by the Maintenance Director to research and implement and more permanent solution.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/08/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villa at Green Lake Estates
6470 Alden Dr Orchard Lake, MI 48324
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility protocol on Lab and Diagnostic Test Results with a revision date of 03/2014 read in part, Assessment and Recognition: 1.
The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs.2.
The staff will process the test requisitions and arrange for tests.3.
The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.An interview with Director of Nursing (DON) was completed on 10/8/25 at approximately 11:35 AM.
The DON was queried about the facility's follow up with the lab process and the lab test results for R901 that was ordered on 8/18/25.
The DON reported that the facility has missed to draw the lab as ordered for R901 and they had identified that the facility was not compliant after R901 was transferred to the hospital.
The DON added that they were reviewing R901's EMR after they were transferred to the hospital on 8/24/25 and identified their non-compliance and facility had completed a Past Non-Compliance (PNC) process.During the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included non-compliance with the facility's lab policy.
Facility identified the concern on 8/24/25. An ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting on 8/24/25 and the facility had a compliance date of 8/25/25.
The Facility PNC report revealed that they were not incompliance with their lab policy between 8/18/25 and 8/24/25.
The facility was able to demonstrate monitoring of the corrective action and maintained compliance during the survey and they were continuing their audits.
Facility ID: