The Villa At Green Lake Estates

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident 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 Resident 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 Resident 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 Resident 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.

Event ID:

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If continuation sheet

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

10/08/2025

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 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # 2615985 Based on interview, and record review, the facility failed to obtain laboratory services ordered by the physician/practitioner for one (Resident R901) of two Residents reviewed for laboratory services. Findings include:A complaint received by the State Agency revealed that the facility failed to follow through with a laboratory (lab) order by the physician to rule out Urinary Tract Infection (UTI) for Resident R901

during their stay at the facility which was also confirmed during an interview with the complainant on 10/3/25 at approximately 11:15 AM.Resident R901 was admitted to the facility on [DATE REDACTED] after hospitalization due to left ankle fracture. Resident R901's admitting diagnoses included intellectual disabilities, pneumonia, and anxiety disorder. Resident R901 was living in a group home prior to hospitalization. Resident R901 had a guardian who was their family member. Resident R901 was transferred to the hospital on 8/24/25 after a fall at the facility.Review of Resident R901's Electronic Medical Record (EMR) revealed a physician order dated 8/18/25 that read, UA (Urinalysis - urine test to rule out infection) C&S (Culture and Sensitivity), CBC (Complete Blood Count) and BNP (B-type Natriuretic Peptide - lab test to rule out heart failure). Further review of Resident R901's medical record revealed an interdisciplinary team note dated 8/20/25 at 12:14 that read in part, .no new orders, no new labs. There were no lab results for the tests that were ordered on 8/18/25 in Resident R901's EMR. 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 Resident R901 that was ordered on 8/18/25. The DON reported that the facility has missed to draw the lab as ordered for Resident R901 and they had identified that the facility was not compliant after Resident R901 was transferred to the hospital. The DON added that

they were reviewing Resident 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet