The Villa At Silverbell Estates
The Villa at Silverbell Estates in Orion, MI — inspection on September 3, 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
.bruising of the .chest .and breast .bruises of an unusual size, multiple unexplained bruises, and/or
after the allegation is made, if the events that cause the allegation involve abuse or result in serious
235396 09/03/2025
The Villa at Silverbell Estates 1255 West Silverbell Road Orion, MI 48359
following:CNA 'G' - I was asked by (LPN 'C') to come in the room (R801) to assess the resident. (LPN
chest, left breast and also noticed a large lump on shoulder near chest area.
She immediately
and everyone said they don't know what was her status before this state that she was in . I told (LPN 'C') this was not her normal state she is usually very alert and responsive.
And the patient was not really responding to questions that (LPN 'C') was asking. (LPN 'C') sent patient out for evaluation due to the condition she was in.Further review of R801's progress notes revealed no documentation by the nurse of the presentation of the discoloration to include the size and color of the discoloration. It should be noted that the progress note written by LPN 'C' only documented what the CNA reported to her.
There was no documentation of how R801 was monitored after CNA 'B' reported the bruising on the afternoon shift until R801 was sent to the hospital at 2:30 AM.
There was no documentation of the change in condition reported by LPN 'C' and CNA 'G' in the above-mentioned interviews.A review of R801's vital signed revealed the last vital signs were taken at 5:19 PM on 7/24/26, approximately nine hours before R801 was sent to the hospital.A review of R801's Skin Observation assessments revealed no documented skin assessment between 7/5/25 and 7/30/25.
Further review of the investigation conducted by the facility revealed a statement by CNA 'I' that noted she saw bruising to R801's chest and/or arm on 7/23/25 but did not report it to anyone. On 9/3/25 at 12:30 PM, an interview was conducted with the Director of Nursing (DON).
When queried about the facility's protocol when a resident had a potential change in condition, the DON stated, In an emergency like that (referring to R801) you just want to ensure the safety of the patient.
When queried about what changed between the afternoon shift and the midnight shift that made LPN 'C' decide to send R801 to the hospital, the DON reported she was on vacation during that time, but R801 was sent out for bruising and did not have a change in condition.
The DON reported she expected the nurses to inspect skin and pain and if the resident did not say she was in pain, the nurse probably just continued on with passing medications.
The DON reiterated that she was not working during the time of the hospital transfer, but that nobody reported a change in condition, just the bruising. It should be noted that the former Administrator conducted the investigation that noted staff's statements about the change in mentation.
The DON was not aware no skin assessments were completed between 7/5/25 and 7/30/25. On 9/3/25 at 12:39 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who said she returned to work the day R801 was sent to the hospital.
When queried about the assessment protocol when a resident had a potential change in condition, the ADON said a full assessment of the resident should be done, including skin assessment, pain assessment, and vital signs and they would be documented in the progress note and/or evaluations.
The ADON did not have an explanation as to why there was no assessment or monitoring between the afternoon shift when CNA 'B' first reported the bruising to LPN 'C and 7/25/25 at 2:30 AM when R801 was sent to the hospital.
The ADON reported she was not aware R801 was acting differently.
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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.