The Villa at Green Lake Estates

In the surveyor’s words

From the most serious findings on record at The Villa at Green Lake Estates, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 8, 2025

  Based on observation, interview, and record review the facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision with a safe environment for one (R900) of four Residents reviewed for falls/accident hazards, who was identified as high fall risk (history of fall with injury), wanderer, with severe cognitive impairment resulting in multiple falls on the staircase or with the step of the staircase, and multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain (using the reasonable person concept). […]

• Immediate jeopardy, isolatedF684Dec 21, 2023

  This citation pertains to intake: MI00141154. Based on observations, interviews, and record reviews the facility failed to ensure a Licensed Practical Nurse (LPN) H Immediately responded to a reported change of condition for R402 who was reported to the nurse as unresponsive, resulting in delayed follow up care, delayed initiation of Cardio Pulmonary Resuscitation (CPR), delayed summoning of Emergency Medical Services and death, for one (R402) of one resident reviewed for CPR. Findings include: The Immediate Jeopardy began on [DATE], when LPN H failed to timely follow up on R402 who was reported as unresponsive. The Administrator and Director of Nursing (DON) was notified of the Immediate Jeopardy on [DATE] at 3:24 PM. […]

• Actual harm, isolatedF686Jul 2, 2025

  R37 On 6/30/25 at 10:15 AM, R37 was observed lying in bed. R37 reported he was not feeling well at that moment and was going to the hospital. When queried about the care in the facility, R37 reported he wore a Life Vest (a wearable cardioverter defibrillator vest that continuously monitors for life-threatening irregular heart rhythms and automatically delivers shock treatment to save a person's life, if needed). R37 reported the vest was not removed because he was to wear it at all times. R37 reported the vest did not fit properly and was very tight which caused a big wound on the trunk of his body where the vest made contact with his skin. R37 reported the facility ordered a new vest, but he never received it. R37 reported the wound was painful and uncomfortable. […]

• Actual harm, isolatedF660Dec 11, 2024

  This citation pertains to intake #: MI00147691, MI00147358 Based on observation, interviews and record review facility failed implement an effective discharge planning process for two (R901 and R902) of two residents reviewed for transfer/discharge, resulting in psychosocial harm using the reasonable person concept for R901 who has aphasia (difficulty communicating due to damage in the brain), a language barrier, and severe cognitive impairment, was discharged to another facility, farther away from family, without approval from the resident's representative and without notification to the other facility; and R902 feeling frustrated and dissatisfied with their living situation. […]

• Actual harm, isolatedF684Oct 10, 2023

  This citation pertains to intake: MI00139836. Based on interviews and record reviews the facility failed to ensure physician orders were transcribed and implemented as ordered by the Physician Assistant, ensure abnormal laboratory results were reported to the physician, ensure an EKG and echocardiogram was completed as ordered by the physician, and ensure the appropriate mode of transportation services were activated to transport the resident to the hospital for one (R909) of one resident reviewed for a change of condition, which resulted in the delay of care including the administration of antibiotics, treatment and medical services and required the resident to be transferred and admitted to the hospital for a higher level of care. […]