The Villa at Silverbell Estates

In the surveyor’s words

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

• Immediate jeopardy, isolatedF690Mar 5, 2021

  This citation pertains to Intake #MI 287. This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to assess, monitor, and implement interventions for one (R#228) of five residents reviewed for bowel management, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an Immediate Jeopardy (IJ) when the resident did not have a bowel movement in four days (96 hours), was not assessed or treated, was experiencing abdominal pain, and was ultimately diagnosed with a mild colonic ileus (occurs when normal movement of the bowels are interrupted which can lead to an intestinal obstruction). […]

• Actual harm, isolatedF686Jun 2, 2026

  This citation pertains to intake: 3006638.Based on interviews and record reviews the facility failed to ensure consistent and appropriate wound management by not completing an admission Braden assessment, not ensuring the timely implementation of wound treatments as ordered by the wound clinician, failing to consistently provide prescribed wound care treatments, failing to timely identify and report to the Physician of the worsening of the wound, and failing to complete labs as directed by the Physician for one (R404) of one resident reviewed for pressure wounds, which resulted in a change of condition and required prolonged hospitalization. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . […]

• Actual harm, isolatedF689Dec 17, 2025

  This Citation pertains to Intake #2685189Based on observation, interview and record review the facility failed to ensure a safe transfer via a Hoyer lift for one (R701) out of two residents reviewed for falls, resulting in R701 sustaining a fracture to the right femur that required surgery and an extensive hospital stay. Findings included: Based on observation, interview and record review the facility failed to ensure a safe transfer via a Hoyer lift for one (R701) of two reviewed for falls, resulting in a fall with fracture to the right femur, pain and Hospital stay. […]

• Actual harm, isolatedF684Jun 18, 2025

  R80 Record review revealed R80 was a long-term resident of the facility, originally admitted on [DATE]. R80 had a recent hospitalization and they were readmitted back to the facility on 3/18/25. R80's admitting diagnoses included pneumonia, congestive heart failure, chronic kidney disease, major depressive disorder, and gout. Based on Minimum Data Set (MDS) assessment dated [DATE], R80 had a Brief Interview for Mental Status (BIMS) score 9/15, indicative of moderate cognitive impairment. R80 had a guardian (daughter) who was making decisions on their behalf. An initial observation was completed on 6/17/25 at approximately 10:20 AM, R80 was observed in their bed with a brief. They had their eyes closed but opened their eyes when called upon but did not answer to any questions. […]

• Actual harm, isolatedF689Jun 18, 2025

  Based on observation, interview, and record review, the facility failed to prevent a fall with major injury for one Resident (R47) of two residents reviewed for falls. This resulted in actual harm for R47, who sustained a left ankle fracture, and a subsequent infection. Findings include: On 6/16/25 at 9:34 a.m., R47 was observed seated in their manual upright wheelchair in the dining room. R47 was leaning to the right side, with their weight distributed mainly over their right hip. Neither leg was supported by footrests. On 6/16/25 at 9:36 a.m., R47 stated, I was standing up to get in my wheelchair and I fell. I broke my foot a few months ago. I have healed up good .They put metal in it (surgical fixation to anchor the joint). […]