THE VILLA AT GREEN LAKE ESTATES

Nursing Home Inspector

6470 ALDEN DR
ORCHARD LAKE, MI 48324
Oakland County
Phone: 248-363-4121
Provider Number: 235489
Last Inspection: 10/12/2016

About the Nursing Home

Number of Beds: 85
Number of Residents: 81
Beds Available: 4
Percent Occupancy: 95%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

63

Facility
35

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

63

2016
11

2015
12

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give the resident's representative the ability to exercise the resident's rights. Isolated : Minimal 3 11/15/2016
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 11/15/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 11/15/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 11/15/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/15/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 11/15/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 11/15/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 11/15/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 11/15/2016
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 11/15/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 11/15/2016
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Potential 3 11/15/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 11/15/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 11/15/2016
 
Failed To: Hire sufficient dietary support personnel. Pattern : Minimal 4 11/15/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 11/15/2016
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Minimal 4 11/15/2016
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 11/15/2016
 

10/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. Isolated : Minimal 3 10/21/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/21/2015
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Potential 3 10/30/2015
 

10/31/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 11/20/2014
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 11/20/2014
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Potential 3 11/20/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/23/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Isolated : Minimal 3 4/10/2017
 

1/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 1/27/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 1/27/2017
 

6/15/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 6/30/2016
 

4/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 4/21/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 81 89.33 85.64
Registered Nurses 0.47 0.91 0.89
Licensed Practical / Vocational Nurses 0.74 1.10 0.84
Certified Nursing Assistants 1.74 2.24 2.54
Total Staff Hours 2.95 4.25 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 3 7 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 88 89 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 85 89 92
of long-stay residents experiencing one or more falls with major injury 2 2 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 12 7 7
of long-stay residents who received an antianxiety or hypnotic medication 33 25 22
of long-stay residents who received an antipsychotic medication 11 12 12
of long-stay residents who self-report moderate to severe pain 1 4 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 14 15 17
of long-stay residents whose need for help with daily activities has increased 6 13 14
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 3 3 3
of low risk long-stay residents who lose control of their bowels or bladder 57 54 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 49 73 80
of short-stay residents who had an outpatient emergency department visit 9 9 11
of short-stay residents who made improvements in function 54 69 71
of short-stay residents who newly received an antipsychotic medication 2 2 1
of short-stay residents who self-report moderate to severe pain 0 12 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 55 74 79
of short-stay residents who were rehospitalized after a nursing home admission 26 24 21
of short-stay residents who were successfully discharged to the community 38 52 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0