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
10/7/25 at 1:54 PM, an interview with Nurse B was completed.
Nurse B confirmed that they were
jeopardy to resident health or asked about their documentation for the fall incident and their assessment/vitals.
Nurse B reported safety 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
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.
235489 10/08/2025
The Villa at Green Lake Estates 6470 Alden Dr Orchard Lake, MI 48324
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.