Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Chaplains Nursing Care Center during CMS and state inspections, most recent first.
A resident’s MDS assessments did not accurately reflect the resident’s psychiatric diagnoses. The resident was admitted with bipolar disorder and PTSD, while a PASSAR also identified schizophrenia and PTSD. One MDS marked bipolar disorder no and PTSD yes, and a later MDS marked bipolar disorder and schizophrenia yes while PTSD was marked no. The RN confirmed the assessments were inaccurate and described the changes as a coding error.
Failure to Reposition Residents With Pressure Ulcers: Two residents with significant pressure injuries were repeatedly observed lying on their backs or on their backside in bed or a recliner without pressure-offloading devices. Both residents were dependent on staff for bed mobility, transfers, and many ADLs, and staff confirmed they needed assistance with repositioning. One resident had an unstageable sacral ulcer, and the other had sacral and bilateral buttock pressure ulcers with a wound vac and a care plan calling for small frequent shifts in position.
Medication administration errors exceeded the allowed rate for three residents. An RN gave duloxetine outside the ordered time, another resident’s morning isosorbide was delayed and held because of timing confusion, and an RN administered Lokelma with furosemide despite not being familiar with Lokelma and not explaining it to the resident. The DON stated meds should be given within 60 minutes of the scheduled time and staff should familiarize themselves with medications before administering them.
The facility failed to prevent cross-contamination by storing cooked noodles under raw pork and did not maintain proper sanitizer concentration in a bucket, as observed by surveyors. These actions violate the 2017 FDA Food Code requirements for food storage and sanitizer use.
The facility failed to serve food at the preferred temperature, as residents reported consistently receiving cold meals. Observations and temperature checks confirmed that food was below the facility's policy standards, impacting palatability. A group of residents also indicated frequent issues with cold food when served in their rooms.
A facility failed to accurately document a resident's discharge disposition. The resident was discharged home with support services and transported via non-emergency ambulance, but the MDS assessment incorrectly recorded the discharge as to the hospital. An interview with the MDS Nurse confirmed the error, highlighting a discrepancy in the documentation process.
The facility failed to notify the local state mental health agency of PASARR Level I changes for a resident with severe cognitive impairment and multiple mental health diagnoses. The resident's medical record showed a PASARR form for a hospital-exempted discharge, but no further PASARR forms were found. The Nursing Home Administrator acknowledged that the necessary forms should have been completed according to facility policies.
A resident with severe cognitive impairment and multiple diagnoses was readmitted to the facility and developed a pressure ulcer. Despite the wound being assessed by a wound care nurse, the care plan was not initiated until 11 days later, contrary to the facility's wound management policy. The wound was documented as deteriorating, highlighting a deficiency in timely care planning.
The facility failed to provide timely podiatry care for a resident and two other residents, resulting in long toenails causing discomfort. The resident had not seen a podiatrist since May 2024, despite being on a list for care. Two other residents expressed dissatisfaction with the podiatry services, and the facility's foot care policy was not provided during the survey.
A resident at moderate risk for pressure ulcers was not provided with an orthotic foot device as ordered by the physician. Observations on multiple occasions revealed the resident in bed without the device, despite a physician's order requiring its use during each shift. The DON confirmed that the expectation was for the physician's orders to be followed.
The facility failed to provide timely care for several residents, with reports of being left on the toilet, waiting hours for assistance, and inadequate incontinence care. Residents required varying levels of assistance for hygiene and transfers, and staff acknowledged challenges in scheduling CNAs for the night shift. Observations noted unresponsive call lights, despite staff presence, indicating a failure to follow facility policies on wound management and call light response.
A resident with a right leg wound had a dressing dated two days prior, despite orders for daily changes. The resident, with impaired cognition and requiring assistance, reported infrequent dressing changes. An LPN acknowledged the oversight, and the DON was unsure why the Treatment Administration Record indicated completion. The facility's policy aims to ensure proper wound care, which was not followed.
Inaccurate MDS Diagnoses
Penalty
Summary
The facility failed to ensure accurate diagnoses were reflected in comprehensive assessments for one resident. The resident was admitted with diagnoses including bipolar disorder and PTSD. A MDS assessment with a reference date of 5/6/25 showed PTSD as an active diagnosis, but bipolar disorder was marked no. A later MDS assessment with a reference date of 11/6/25 showed bipolar disorder and schizophrenia as active diagnoses, while PTSD was marked no. A PASSAR dated 4/15/25 identified schizophrenia and PTSD. During interview, the Regional Clinical RN confirmed the MDS assessments were not accurate and stated they were uncertain why the former MDS nurse manually changed the bipolar and schizophrenia diagnosis in November, describing it as a coding error. The RN also stated the MDS nurse is to follow the RAI manual when completing MDS assessments.
Failure to Reposition Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for two residents who were dependent on staff for bed mobility and transfers and who had significant pressure injuries. R11 was admitted with diagnoses including respiratory failure, heart failure, and above-knee leg amputation, and the record documented a sacral pressure ulcer that was unstageable with slough and eschar. R11’s care plan and MDS reflected dependence on staff for rolling, sitting, and transfers, yet the resident was repeatedly observed lying on the back or on the backside in bed, often with the head of the bed elevated and without positioning devices to offload pressure. R11 was also observed leaning down in bed and eating meals while positioned on the backside in bed. R78 was admitted with diagnoses including a sacral pressure ulcer, cervical spinal cord injury, and dehydration, and the care plan documented stage four sacral and stage three bilateral buttock pressure ulcers, a wound vac, and the need for small frequent shifts in position. The MDS showed dependence on staff for rolling, toileting, dressing, bathing, and transfers, with substantial to maximal assistance needed for eating and personal hygiene. Despite this, R78 was repeatedly observed lying on the back in bed or seated in a recliner on the backside with the head down, with the heels resting on the bed surface and no devices observed to relieve pressure from the back, tailbone, or buttocks. Therapy notes and staff statements confirmed that both residents required assistance for repositioning. The Therapy Manager reported that R11 had bed mobility, transfers, and ADLs that were max to dependent on staff, and that R78 was max assist to dependent for dressing, toileting, bathing, and grooming, moderate assist for bed mobility, and dependent for transfers. A CNA stated that both residents required staff assistance for repositioning, and an LPN reported that R78 generally needed assistance to reposition. The wound nurse stated that timely repositioning, wheelchair cushions, treatments as ordered, and physician collaboration were required for residents with pressure sores such as R11 and R78.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate below 5% for three of six residents reviewed for medication administration. During an observation and interview, an RN prepared medications for a resident with a history of depression and removed a medication pack labeled for 7:00 a.m. to 10:00 a.m. that included duloxetine, even though the physician’s order was for duloxetine 60 mg to be given at 12:00 p.m. The RN stated the medication was given at 10:00 a.m. because it was in the pack with the other medications for that time, while the MAR later documented duloxetine as given at 12:00 p.m. For another resident, isosorbide ordered for morning administration was found packaged with morning medications, but an RN reported it had not yet been given and was being held to confirm with the doctor. A regional clinical RN stated that new medication orders processed in the afternoon were given on the afternoon shift even when ordered as morning medications, which caused the order to be submitted as an afternoon or morning administration. For a third resident, Lokelma and furosemide were both administered in the morning, and the RN who gave the medications stated she was not familiar with Lokelma and did not explain it to the resident; the DON stated medications should be administered within 60 minutes of the scheduled time and that unfamiliar medications should be looked up.
Food Storage and Sanitizer Deficiencies
Penalty
Summary
The facility failed to properly store food to prevent cross-contamination and did not maintain adequate sanitizer concentration in the sanitizer bucket. During an observation, a pan of cooked noodles was found stored directly underneath a box of raw pork in the reach-in cooler, which was confirmed by Dietary Staff H as inappropriate storage. This practice is contrary to the 2017 FDA Food Code section 3-302.11, which mandates the separation and proper arrangement of raw and cooked foods to prevent cross-contamination. Additionally, a red bucket filled with sanitizer was tested and found to have no detectable sanitizer concentration, as the test strip did not change color. Dietary Staff H acknowledged the issue and stated the bucket would be emptied and refilled. This is a violation of the 2017 FDA Food Code, Section 3-304.14, which requires that cloths used for wiping surfaces be held in a chemical sanitizer solution at the specified concentration.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at the preferred temperature for several residents, leading to dissatisfaction with food palatability. During interviews, residents expressed that the food was consistently cold, with one resident noting that the only alternative menu item available was a peanut butter and jelly sandwich. Observations confirmed that meal trays were being distributed from an open food cart, and a random food tray temperature check revealed that the food was below the facility's policy standards for hot food temperatures. The Dietary Manager confirmed that the food tasted good but was cold, and a surveyor also noted that the food tasted warm to cold, negatively impacting its palatability. A group meeting with residents further revealed that the majority experienced cold food when served in their rooms. The facility's policy stated that hot food temperatures should not be below 120 degrees Fahrenheit at the point of service, yet the observed temperatures were significantly lower, indicating a failure to adhere to the policy.
Inaccurate Discharge Documentation
Penalty
Summary
The facility failed to accurately document the discharge disposition of a resident, identified as R85, during a review of records and interviews. The records indicated that R85 was discharged home with support services and appropriate equipment, and was transported home via non-emergency ambulance. However, the Minimum Data Set (MDS) assessment information inaccurately recorded the resident as being discharged to the hospital. An interview with the MDS Nurse B confirmed that the discharge was recorded incorrectly. The facility's policy for completing an MDS involves using the Resident Assessment Instrument (RAI) manual, which emphasizes that the assessment should accurately reflect the resident's status.
Failure to Notify Mental Health Agency of PASARR Changes
Penalty
Summary
The facility failed to notify the local state mental health agency of Pre-Admission Screening and Resident Review (PASARR) Level I changes for a resident reviewed for PASARR completions. The clinical record revealed that the resident was admitted with diagnoses including alcohol abuse, alcohol-induced psychotic disorder with delusions, adjustment disorder with anxiety, cognitive communication deficit, and delirium. The Minimum Data Set (MDS) assessment indicated a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 00. A review of the resident's medical record showed a PASARR form 3877 Hospital Exempted Discharge dated for a specific date, which covers a resident admission for 30 days and requests a level II for mental health services. However, upon request, the Social Worker stated that no other PASARR forms were found for the resident. The Nursing Home Administrator confirmed that the level II and other forms should have been completed as per the facility's policies.
Delayed Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to timely initiate a care plan for a resident with a pressure ulcer, which was identified as a deficiency. The resident, who was readmitted with multiple diagnoses including heart failure, diabetes, and dementia, was found to have a skin tear reported by a CNA on November 3, 2024. The wound care nurse assessed the wound on November 4, 2024, noting it was related to shearing. However, the care plan for this wound was not initiated until November 14, 2024, which was 11 days after the initial discovery of the skin impairment. The wound was documented by a physician on November 11, 2024, as an unstageable pressure injury that was deteriorating, with specific measurements and characteristics noted. Despite the worsening condition, the care plan was delayed. The facility's policy on wound management requires the development of an individualized care plan when a pressure ulcer is identified, but this was not adhered to in a timely manner. The wound continued to deteriorate, as noted in a wound note dated November 18, 2024, indicating a lack of timely intervention and care planning for the resident's condition.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident and two other residents, as observed during a survey. One resident was found with long toenails extending past the tips of their toes, causing discomfort when wearing shoes. This resident had been waiting for podiatry care for an extended period and had not seen a podiatrist since May 2024, despite having a diagnosis of peripheral vascular disease. The facility's social worker confirmed that the podiatry service had not been available for a long time due to the loss of their doctor, and the resident was on a list to be seen by podiatry. During a confidential group meeting with eight residents, two expressed dissatisfaction with the podiatry services, indicating they had not seen a podiatrist in a long time and needed their toenails cut. The facility's Director of Nursing confirmed that residents' nails are assessed weekly, and those with long toenails are put on a list for podiatry. However, the last podiatry visit was in May 2024. The facility's foot care and ancillary services policy was requested but not provided by the end of the survey.
Failure to Implement Orthotic Device for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement an orthotic foot device as per the physician's order for a resident at risk of developing pressure ulcers. The resident, identified as having a moderate risk of pressure ulcer development with a Braden Scale Assessment score of 13, was observed on multiple occasions without the prescribed orthotic foot device while in bed. Specifically, on two separate days, the resident was seen lying in bed without the device, and a nurse was also observed providing care without ensuring the device was in place. The physician's order, dated several months prior, clearly stated that the orthotic device should be worn while the resident is in bed for each shift. The Director of Nursing confirmed that the expectation was for the physician's orders to be followed as written. The facility's Wound Care Management Program policy emphasizes the importance of providing treatment and services to promote healing and prevent new skin conditions, which was not adhered to in this case.
Deficiencies in Timely Care and Response to Resident Needs
Penalty
Summary
The facility failed to provide timely care for several residents, as observed through interviews and record reviews. One resident reported being left on the toilet during the afternoon shift and not receiving water when requested. This resident required partial assistance for transfers and hygiene, as documented in their care plan. Two other residents reported waiting for hours for assistance during the night shift, with one experiencing a significant delay in receiving pain medication. Both residents required varying levels of assistance for personal hygiene and transfers. Another resident was found to have a wound on their buttocks and was left wet and soiled for extended periods, as noted in a care complaint. This resident had impaired cognition and was dependent on staff for toileting and transfers. A different resident also reported being left wet and soiled, with a strong urine odor noted in their room. This resident required substantial assistance for hygiene and transfers. Staff acknowledged challenges in scheduling CNAs for the night shift, which may have contributed to these issues. Additionally, a resident reported that the night shift was particularly unresponsive, leading to prolonged periods without assistance. This resident had a sore on their bottom and required full assistance for hygiene and transfers. Observations during the survey noted call lights activated without response, despite staff presence in the hallway. The facility's policies on wound management and call light response were not adequately followed, contributing to the deficiencies in care.
Failure to Change Dressing as Ordered
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as R706, who was observed with a dressing on their right leg dated two days prior to the observation. The resident, who had undergone surgery on their leg, reported that the facility changed the dressing sporadically. The medical record indicated that R706 was admitted with a cutaneous abscess of the right foot and sepsis, and had an impaired cognition with a Brief Interview for Mental Status score of 11/15. The resident required assistance with bed mobility and transfers, and had active orders for daily dressing changes on their right plantar heel and right heel, which were not followed as observed. During the survey, an LPN confirmed that the dressing should be changed daily and planned to change it that morning. The Director of Nursing (DON) was unsure why the dressing was not changed as per the Treatment Administration Record (TAR), which indicated it was completed. The facility's Wound Management Program policy aims to ensure residents receive treatment to promote healing and prevent complications, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Bleu Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 11 | 0 |
| Optalis Health And Rehabilitation Of Dearborn Heig | 2.4 mi | ★★★★★ | 20 | 0 |
| Regency At Livonia | 2.7 mi | ★★★★★ | 12 | 0 |
| Majestic Care Of Livonia | 3.7 mi | ★★★★★ | 12 | 0 |
| Livonia Woods Nursing And Rehabilitation | 4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.