The Villa At Silverbell Estates

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

to the Administrator. At that time, the FRI investigation was reviewed with the Administrator. When queried about the statement written by CNA 'I' that noted she identified bruising on 7/23/25 but did not report to anyone, the Administrator reported the injury should have been reported at that time. When queried about LPN 'C' not reporting to the Administrator until 2:30 AM on 7/25/25, when CNA 'B' notified her of the bruising on 7/24/25 during the afternoon shift, the Administrator reported it should have been reported immediately based on the extent of the bruising. A review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed , in part,

the following: .An injury should be classified as an injury of unknown source when both of the following conditions are met .The source of the injury was not observed by any person or the source of the injury could not be explained by the resident .The injury is suspicious because of the extent of the injury or the location of the injury .or the number of injuries observed at one particular point in time of the incident of injuries over time .Investigation of injuries of Unknown or Suspicious injuries: must be immediately investigated to rule out abuse: .injuries include, but are not limited to .bruising of the .chest .and breast .bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma .The facility will ensure that all alleged violations .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials .

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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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Villa at Silverbell Estates

1255 West Silverbell Road Orion, MI 48359

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

reported Resident R801 typically communicated with staff. CNA 'G' said she saw a dark colored bruise on her breast, back area, and collar bone area. CNA 'G' stated, I was really concerned about the resident. At that time, LPN 'C' called 911 and reported it to the Administrator. A review of an investigation conducted by the facility revealed statements written by staff that revealed the following:CNA 'G' - I was asked by (LPN 'C') to come

in the room (Resident R801) to assess the resident. (LPN 'C') look at the patient arm and noticed bruises on her left arm. (LPN 'C') observed the patients skin for assessment also (LPN 'C') pulled the gown down to look further and noticed a big bruise on her chest, left breast and also noticed a large lump on shoulder near chest area. She immediately contacted the administrator. (LPN 'C') asked multiple staff did anyone know how her patient status is 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 Resident 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 Resident R801 was monitored after CNA 'B' reported the bruising on the afternoon shift until Resident 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 Resident R801's vital signed revealed the last vital signs were taken at 5:19 PM on 7/24/26, approximately nine hours before Resident R801 was sent to the hospital.A review of Resident 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 Resident 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 Resident 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 Resident R801 to the hospital, the DON reported she was on vacation during that time, but Resident 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 Resident 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 Resident R801 was sent to the hospital. The ADON reported she was not aware Resident R801 was acting differently.

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