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 Majestic Care Of Livonia during CMS and state inspections, most recent first.
Ice machine cross-connection prevention failed when the Station 2 pantry ice machine drain line was observed submerged into the pump reservoir without the required air gap. The MD stated the issue would be added to the maintenance task list and corrected.
A resident with Down Syndrome, major depressive disorder, moderate intellectual disabilities, severely impaired cognition, and a documented history of refusing showers/ADLs was subjected to a shower despite clearly stating they did not want one. The assigned CNA and another CNA reported hearing the resident repeatedly refuse the shower while an assisting CNA told the resident they were going to take the shower. The resident was observed with wet clothes and soap on their face, and an LPN observed the resident in the shower room with clothes still on, a soiled shirt on the floor, and the resident at the sink with pants down. These events occurred despite a facility policy affirming residents’ rights to self-determination and to refuse care.
Multiple residents with significant mobility, cognitive, and sensory impairments did not receive timely assistance with ADLs or prompt responses to call lights. One resident with paralysis and heart disease reported call lights going unanswered for over thirty minutes and showed video of empty hallways, leading them to get out of bed without needed help. Another resident with paraplegia reported delayed incontinence and wound care and was observed waiting at their doorway and then at the nurse station for assistance to be changed. A resident with quadriplegia and severe cognitive impairment was repeatedly observed lying on their back in bed or in a recliner without effective use of positioning devices to offload pressure. A legally blind resident who required help with ambulation and dressing waited extended periods for staff to escort them from the dining room and to the bathroom, with their call light ultimately answered by the DON rather than unit staff. Another cognitively intact resident needing ADL assistance reported call lights sometimes taking over an hour to be answered and was observed having their call light turned off by staff before the requested brief change was provided, contrary to facility policy requiring timely call light response.
Late Transmission of Death in Facility MDS Assessment: A resident with acute and chronic respiratory failure with hypoxia died in the facility after a change in condition was noted and the physician pronounced death. The MDS assessment for the death in facility event was not encoded and transmitted to CMS until later, exceeding the 14-day requirement, and the resident’s MDS list showed the assessment as overdue.
Failure to complete and follow up on MRRs. The facility did not ensure timely pharmacist review and response for two residents. One resident remained on risperidone for bipolar disorder even though the chart did not show a bipolar diagnosis, despite a pharmacist recommendation to review the chart and add an appropriate diagnosis or discontinue the medication if none existed. For another resident with dementia, depression, and paranoid schizophrenia, several MRRs were not provided to surveyors by the end of survey, and the facility's Pharmacy Services did not address timely completion and follow up of MRRs.
Food was not prepared to meet the preferences or palatability needs of two residents. One resident reported hard cereal, grainy oatmeal, no butter on the tray, and a hard croissant sandwich, while another resident said the food was generally nasty and rarely something they liked. A tray review found toast that was soft and difficult to cut and a dry sausage patty that pulled apart; the resident also had dx of right-sided paralysis, stroke, and heart disease.
A resident’s medical record was not accurate when an MD/NP/PA progress note documented female anatomy and a vaginal ultrasound for a male resident who was trach-dependent and had severe cognitive impairment. The DON stated the physician who wrote the note was no longer with the facility due to ongoing concerns related to issues such as these.
A resident's prescribed narcotic pain medication was misappropriated when two sleeves of Norco were delivered but only one was accounted for, with the discrepancy occurring while the medication was under the care of an LPN. The issue was discovered after a pharmacy refill request was denied, and investigation revealed a hand-written label on the count sheet and missing medication. The resident received pain medication from the emergency backup supply, and no other discrepancies were found in other residents' narcotics.
A resident with severe cognitive impairment had multiple incidents of inappropriate contact with another resident. The facility failed to update the care plan with new interventions after the initial incident, despite further occurrences. Staff confirmed monitoring was initially increased but later reduced, and the facility's policy did not address care plan revisions for significant events.
The facility did not ensure RN coverage for at least eight consecutive hours on a weekend day, as required. A review of the nurses' schedule showed no RN was on duty on a specific date due to the scheduled RN's illness. This was confirmed by the scheduler staff and the Nursing Home Administrator.
An inspection revealed deficiencies in food storage and pest control, including undated food items in coolers, swarms of gnats near the dish machine, and standing water issues. The Dietary Manager could not explain these issues, which violate FDA Food Code requirements for food safety and pest control.
A resident with severely impaired cognition and requiring substantial assistance was referred to with potentially derogatory language in a care order. An LPN used the term 'feeder' to describe meal assistance, which was later confirmed as inappropriate by both the LPN and the DON. The facility's policy on dignity was not upheld, as it emphasizes treating residents with respect and dignity.
A resident with a history of falls and a diagnosis of hemiplegia was found with a bruise from a fall, yet their care plan had not been updated since May 2023. The facility's DON admitted to not completing necessary steps post-fall, and the facility lacked a specific policy for care plan revisions after falls, despite having a Fall Prevention policy requiring such updates.
A resident with Alzheimer's disease and severe cognitive impairment was observed multiple times without the necessary hand splints, which were prescribed to be worn at all times except for hygiene. Despite physician orders and facility policy emphasizing the importance of consistent use, the resident was seen with contracted hands and difficulty eating, indicating a failure in care by the facility.
The facility failed to date opened biologicals in three medication carts, including insulin vials, glucose test strips, and eye droppers. Observations revealed undated items in the A, D, and C medication carts. The DON confirmed the requirement to date these items, aligning with the facility's policy and manufacturer guidelines.
The facility failed to provide food that was palatable and presentable for three residents, leading to dissatisfaction with taste and variety. One resident, a newer admission for rehabilitation, expressed concern over the food's taste and variety, while another criticized the eggs and bread quality. A third resident noted issues with the grits' texture and the presentation of meals. The facility's dietary staff acknowledged these complaints, and the Nutritional Services policy lacked guidance on food palatability and presentation.
A resident with a documented seafood allergy was mistakenly served shrimp, leading to an allergic reaction. The resident, believing the dish was chicken, experienced a tingling sensation in their mouth and tongue after consuming the shrimp. A CNA notified an LPN, who administered Benadryl. The incident was not documented in the resident's medical records, and the dietary management confirmed the allergy was clearly marked on the meal ticket. The facility's policy requires allergies to be noted on tray cards, which was not followed.
A facility failed to implement proper transmission-based precautions for a resident with an infection, as staff did not consistently use PPE or perform hand hygiene. Additionally, the facility did not ensure timely dressing changes for a resident's PICC line, as required by physician orders. These deficiencies highlight lapses in adherence to infection prevention and vascular access management policies.
The facility failed to provide adequate hygiene care and meal assistance to two residents. One resident, who required assistance with bathing, had not received a shower in over a month despite being scheduled for twice-weekly showers. Another resident with severe cognitive impairment and a need for 1:1 assist feeding was observed with uneaten meals and nutritional drinks left untouched. The facility did not adhere to its policy on activities of daily living, resulting in deficiencies in both hygiene care and meal assistance.
A facility failed to apply lymphedema wraps for a resident with heart failure and swelling, despite a physician's order. The resident reported increased swelling, and observations confirmed the absence of wraps. Additionally, another resident with severe cognitive impairment and a stage 2 wound was not repositioned regularly, lacking a necessary positioning wedge. Staff confirmed the resident's need for assistance, and the DON acknowledged the requirement for regular repositioning.
The facility failed to provide adequate tube feeding and hydration for a resident, as their tube feeding was not connected despite physician orders. Another resident with severe cognitive impairment did not receive meal assistance or nutritional supplements as prescribed, leading to weight loss. The facility's policies on enteral feeding and nutrition management were not followed, resulting in these deficiencies.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to a deficiency. The resident was issued an involuntary discharge notice without prior awareness, triggering a traumatic reaction. The care plan lacked interventions to address PTSD triggers, and there was no documentation of a PTSD assessment. Facility staff were unaware of the resident's PTSD diagnosis until after the incident, highlighting deficiencies in trauma-informed care practices.
A resident with paraplegia and a stage three pressure ulcer was not repositioned as required, leading to a deficiency in skin care management. Despite the care plan's directive for routine repositioning and assistance, the resident was observed lying on their back for extended periods without pressure-relieving devices. The facility's policy emphasizes pressure redistribution, but the expected repositioning every two hours was not adhered to.
A resident with Alzheimer's and mobility issues was left in a wet incontinence pad and bedding for several hours, despite clean supplies being available. The CNA confirmed the resident was only changed once in the morning, contrary to the facility's policy of checking and changing every two hours. The DON acknowledged this was unacceptable.
A facility failed to follow hospital discharge instructions for a resident with Multiple Myeloma, resulting in missed follow-up appointments with specialists. The resident or their daughter canceled an initial oncology appointment, and subsequent appointments were not documented as attended. Staff changes and transportation concerns contributed to the deficiency.
A resident with multiple health conditions was not allowed to return to the facility after hospitalization due to aggressive behavior and non-compliance with care. Despite being medically and psychiatrically cleared, the facility cited a lack of staff to manage the resident's needs and safety concerns for staff as reasons for refusal. The facility's actions were based on their Transfer and Discharge policy, which allows for discharge if a resident's needs cannot be met or if safety is endangered.
A resident with impaired cognition and a history of schizoaffective disorder eloped from the facility without injury. Staff interviews revealed that an alarm sounded but was turned off by an employee, and a food delivery was placed near the alarming door. The facility's elopement policy was not effectively implemented, leading to the resident's unsupervised exit.
A resident with impaired cognition and multiple diagnoses developed a pressure ulcer that worsened due to the facility's failure to implement timely wound care treatments. Despite the initial identification of a wound on the sacrum, a treatment order was delayed for 19 days, leading to the progression of the wound to a stage 3 ulcer. The DON acknowledged the lapse in following the facility's policy for wound prevention and care.
The facility failed to honor residents' rights to self-determination regarding Leave of Absences (LOAs) by implementing restrictive guidelines. These included specific times for LOAs, weather-related restrictions, and the requirement for residents to be accompanied by a community member. The guidelines were established after discussions with the medical director, law enforcement, and community members due to concerns about resident behaviors in the community. The restrictions contradicted the facility's Therapeutic Leave policy, which allowed residents to leave for non-medical visits in accordance with federal and state guidelines.
The facility failed to consistently assist the Resident Council in holding monthly meetings, as identified during a mock survey. The NHA acknowledged the deficiency, presenting incomplete or undated meeting notes. The turnover of three Activity Directors in the past year contributed to disorganized records, violating the policy that mandates monthly meetings with resident participation.
The facility did not have a qualified professional directing the activities program, affecting all 95 residents. The NHA noted a new Activities Director was hired recently, but there was no one in the role when he started. The current Activities Director began in June, and an Activities Aide confirmed the absence of a director since April. The DON recalled the last director was in March. The Activities Policy lacked details on qualifications.
A resident diagnosed with Schizoaffective Disorder-Bipolar Type, Anxiety Disorder, Violent Behavior, and Vascular Dementia eloped from the facility despite wearing a Wanderguard ankle bracelet. The resident's care plan included interventions for wandering and exit-seeking behaviors. However, the resident managed to leave undetected, and staff became aware of the elopement approximately eight hours later. Staff interviews revealed inconsistencies in recollections of door alarms, and surveillance footage showed the resident outside the facility for several hours before being noticed missing.
Ice Machine Drain Line Lacked Required Air Gap
Penalty
Summary
The facility failed to ensure appropriate cross-connection prevention when the Station 2 pantry ice machine drain line was observed submerged into the pump reservoir without the required air gap. This condition was identified during observation, and the Maintenance Director stated during the interview that the issue would be added to the maintenance task list and corrected.
Failure to Honor Resident’s Refusal of Shower and Right to Dignified Care
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to refuse care and to be treated with dignity when staff proceeded with a shower despite the resident’s verbal refusals. The resident, who had Down Syndrome, major depressive disorder, moderate intellectual disabilities, a BIMS score of 3/15 indicating severely impaired cognition, and a documented history of refusing showers/ADLs, was the subject of a complaint alleging they were forced to shower. According to the facility’s investigation, the CNA assigned to the resident requested assistance from another CNA. The assigned CNA reported hearing the resident say, "I don't want to take a shower; I don't want to take a shower," and heard the assisting CNA respond, "you're going to take this shower." Another CNA, who was nearby, also reported hearing the resident repeatedly say "No shower" and a CNA telling the resident, "you are going to take a shower." The investigation further documented that the assisting CNA stated the shower was already running and spraying water on the resident when they entered the shower room, and that the resident left the shower room and walked to their room with wet clothes on before staff could assist. The assigned CNA reported returning to the shower room and observing the resident wearing wet clothes with soap on their face. An LPN reported being told by the assigned CNA that the assisting CNA had started wetting the resident while the resident’s clothes were still on, and the LPN observed the resident in the shower room with clothes still on, a soiled shirt on the floor, and the resident at the sink with their pants down. The facility’s resident rights policy states that residents have the right to a dignified existence, self-determination, and to make choices about schedules and care, including the right to refuse showers or care.
Failure to Provide Timely ADL Assistance and Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs) and to respond promptly and appropriately to call lights for multiple residents. One resident with right-sided paralysis, stroke, and heart disease, who required partial to moderate assistance for mobility, reported that on afternoon and night shifts their call light was sometimes left unanswered for more than thirty minutes. The resident and a family member stated there was a camera in the room and played a video showing empty hallways during late afternoon and nighttime hours. When the call light was not answered, the resident reported having to get out of bed independently despite documented needs for assistance. Another resident with paraplegia and schizophrenia, who was care planned as requiring assistance with ADLs and having episodes of incontinence, reported not receiving timely wound care and stated that dressings on their feet had not been changed in two weeks. This resident also reported needing assistance to change their brief due to urinary incontinence. On one observation day, the resident was seen in a powered wheelchair at their doorway stating they were waiting for assistance, while three staff were in the area and one walked by without acknowledging them. After waiting, the resident moved to the nurse’s station to request help and later complained of having waited thirty minutes for assistance to be changed. The DON acknowledged awareness of this resident’s care needs and behavior history, including reports that the resident was not always truthful about care requests. A resident with quadriplegia, bilateral hand contractures, dementia, and severe cognitive impairment, who was dependent on staff for all ADLs including bed mobility, transfers, and personal hygiene, was repeatedly observed lying on their back in bed or in a recliner for extended periods without effective use of positioning devices to offload pressure. Over multiple observations across several days, the resident remained on their back in bed or in a medical recliner, often with wedges or pillows present but not positioned under the resident in a way that would offload pressure from the back and buttocks. The resident was also observed with apparent foot drop and heels resting directly on surfaces without protective devices in place. Another resident with legal blindness, adjustment disorder, and a history of falls, who required assistance with ADLs and minimal assistance for most tasks, reported needing help to get dressed and to walk with a walker to the dining room but was later observed eating lunch in their room instead. On a subsequent day, this resident was seen seated at a dining room table before lunch and remained there for an extended period, asking if their aide was available to walk them back to their room while no staff were visible in the halls or at the nurse station. The resident later reported that restorative staff, who walk with them a few times a week, had assisted them back to their room. The same resident activated their call light to request help to the bathroom; several minutes later, the DON happened to walk by, answered the call light, and assisted the resident, with no other staff responding. The resident also reported having requested a t-shirt from night staff to wear under their hospital gown and not receiving it. A further resident, cognitively intact and requiring staff assistance for ADLs following a right lower leg bimalleolar ankle fracture, reported that staff sometimes took over an hour to answer call lights. During one observation, this resident’s call light was on for several minutes before staff arrived and the resident requested a brief change. Staff then went to the nurse’s station, returned to the room, and turned off the call light despite the resident asking to keep it on because staff often did not return once the light was turned off. The resident explained that staff frequently turned off the call light without providing the requested care. Facility policies reviewed by surveyors stated that comprehensive care plans must be implemented to meet residents’ medical, nursing, mental, and psychosocial needs, and that all staff are responsible for responding to call lights and ensuring requested services are provided in a timely manner.
Late Transmission of Death in Facility MDS Assessment
Penalty
Summary
The facility failed to timely submit an MDS resident assessment for one resident, R77, whose MDS assessment was triggered for being 120 days overdue. During interview, the MDS Coordinator, an LPN, stated that R77 had died at the facility and that she would look into why the assessment was overdue. The resident’s record showed a general progress note documenting that at 9:50 AM an aide noticed a change in condition, the nurse was notified, and at 10:31 AM paramedics called the hospital physician, who pronounced the resident dead at 10:31 AM. Further review of the record showed that R77 was admitted to the facility on one date, readmitted on another date, and later discharged/expired on [DATE]. The resident’s primary diagnosis was acute and chronic respiratory failure with hypoxia. The list of MDS assessments did not include a death in facility assessment and showed the overdue assessment in red print. The LPN later confirmed that the death in facility assessment was not encoded and transmitted to the CMS database until that day, which exceeded the 14-day requirement stated in the CMS RAI Manual for entry and death in facility tracking records.
Failure to Complete and Follow Up on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure timely completion and follow up of Medication Regimen Reviews (MRRs) for two residents. For one resident with diagnoses including Alzheimer's disease, unspecified psychosis, and generalized anxiety, the medical record showed a pharmacist recommendation on 1/14/26 stating that risperidone was being used for bipolar disorder without a listed diagnosis to support that indication, and that the chart should be reviewed and an appropriate diagnosis added or the medication discontinued if no diagnosis existed. On 2/27/26, the resident's active physician order still listed Risperdal 1 mg by mouth twice daily for bipolar disorder, and the resident's diagnoses did not include bipolar disorder. For another resident with diagnoses including dementia, depression, and paranoid schizophrenia, the record showed multiple MRRs with recommendations completed across several months. These recommendations were requested from the facility on 2/27/26 at 9:24 AM, but the facility did not provide several of the MRRs by the end of survey, including those dated 12/10/25, 11/12/25, 8/11/25, 6/12/25, and 1/8/25. Review of the facility's Pharmacy Services did not address the timely completion and follow up of MRRs.
Food Not Prepared to Meet Resident Preferences or Palatability Standards
Penalty
Summary
The facility failed to provide food that met resident preferences and was palatable for two residents. One resident reported that the food was “so so,” the menu was not really good, cereal was sometimes hard, oatmeal was not liked when it was regular oatmeal, and the alternate meals were not consistent because they did not really like pork or beef. The resident also stated they had complained about the food and felt it had gotten worse. The resident was observed eating lunch in their room, and on another observation reported the oatmeal was grainy and not sweet enough, no butter was present on the tray, and a croissant breakfast sandwich was hard; the croissant was hard to the touch on both halves and clanked on the plate when tapped. A second resident reported the food was generally nasty, was rarely served something they liked to eat, and felt they were not being heard. That resident had multiple boxes of dry cereal and additional items in a refrigerator. A test tray review found the breakfast sandwich had two slices of toast, a square egg with cheese, and a circular sausage patty; the toast was not crunchy and was more sponge-like, soft, and difficult to cut, and the sausage patty was dry, difficult to cut, and pulled apart. The resident’s record showed diagnoses of right-sided paralysis, stroke, and heart disease, with intact cognition on MDS and partial to moderate assistance needs for transfers and setup for some activities. The facility policy stated food shall be prepared to maintain nutritional value, palatability, and visual appeal while meeting therapeutic and texture-modified diet requirements.
Inaccurate Resident Medical Record Documentation
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately reflected the resident’s care. The resident was a male admitted with diagnoses of unspecified intracranial injury, anemia, and hypertension, and the record also noted severe cognitive impairment and total dependence for activities of daily living. A progress note entered by an MD/NP/PA stated that the resident was tracheostomy-dependent and also documented that the patient had a status for vaginal ultrasound because of a possible endometrial CA, despite the resident being male. When the DON was asked about the note, she stated the physician who wrote it was no longer with the facility due to ongoing concerns related to issues such as these. The facility’s documentation policy required records to be factual, objective, resident-centered, accurate, relevant, and complete.
Failure to Prevent Misappropriation of Controlled Substance
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's prescribed controlled substance, specifically a narcotic pain medication. The incident involved a resident with diagnoses of metabolic encephalopathy and end stage renal disease, who required staff assistance with activities of daily living and had intact cognition. The issue was discovered after a pharmacy refill request for the resident's pain medication was denied due to being too early, prompting further investigation by the Director of Nursing (DON). Upon review, it was found that two sleeves of 30 Norco 10/325 pills each had been delivered to the facility, but only one sleeve was accounted for on the narcotic count sheet. The count sheet for the missing medication had a hand-written identification label instead of the standard pharmacy-provided sticker. By cross-referencing pharmacy records, handwriting, and staff schedules, it was determined that the discrepancy occurred while the medications were under the care and control of an LPN. The resident received pain medication from the facility's emergency backup supply during this period. The facility's investigation did not uncover evidence supporting alternative explanations for the missing medication. Audits of other residents' narcotics did not reveal further discrepancies. The facility's policies require controlled substances to be stored securely and for any discrepancies in controlled medication counts to be reported and investigated immediately, but these procedures were not effectively followed in this instance, resulting in the misappropriation of the resident's medication.
Failure to Revise Care Plan After Multiple Incidents
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R702, following multiple incidents of inappropriate contact with another resident, R703. The initial incident occurred on 12/20/24 and was directly witnessed by staff, who intervened immediately. Despite this, the care plan for R702 was only updated with interventions following the first incident, and no further interventions were added after subsequent incidents on 01/01/25 and 01/20/25. R702 has a diagnosis of Dementia and Disorientation, with a BIMS score indicating severe cognitive impairment. The care plan included a focus area addressing R702's behavior, but it was not adequately revised to reflect ongoing issues. Interviews with staff, including a physical therapist and an LPN, confirmed that R702's behavior had been monitored, with checks every 30 minutes initially implemented but later lifted. The facility's policy on comprehensive care plans did not specifically address the need for revisions in response to significant events, which contributed to the oversight. The facility's administrator and DON acknowledged the deficiency, noting that interventions had been effective but were not documented in the care plan as required.
Failure to Provide RN Coverage on Weekend
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours per day on weekends, specifically on December 7, 2024. This deficiency was identified through a review of the nurses' schedule for four weeks in November and December 2024, which revealed the absence of documented RN coverage on the specified date. During an interview on December 10, 2024, the scheduler staff confirmed the lack of RN on duty on December 7, 2024. Additionally, the Nursing Home Administrator, in an email exchange, confirmed with the Director of Nursing (DON) that the scheduled RN was unable to work due to illness, resulting in no RN coverage on that day.
Food Storage and Pest Control Deficiencies
Penalty
Summary
During an inspection of the kitchen, several deficiencies were observed related to food storage and pest control. In the walk-in cooler, multiple food items, including a pan of soup, bags of chicken and ham, and packages of hot dogs and tomato sauce, were found without proper date markings. Additionally, a crate of milk was past its use-by date. In the Traulsen reach-in cooler, containers of Italian dressing, sweet and sour sauce, and BBQ sauce were also undated or past their use-by dates. The Dietary Manager was unable to provide an explanation for these issues. According to the 2017 FDA Food Code, ready-to-eat, potentially hazardous food must be clearly marked with a date to ensure it is consumed or discarded within a safe timeframe. Further inspection revealed pest control issues in the dish machine room, where swarms of gnats were observed near the soiled side of the dish machine. Standing water was found underneath the sink basin, and missing grout between floor tiles allowed water to accumulate. The Dietary Manager acknowledged that a pest control company treats the drains but did not explain the stagnant water issue. Additionally, spilled milk was found pooled at the bottom of the Motak milk cooler, and undated food items were discovered in the resident refrigerator. These conditions violate the FDA Food Code requirements for maintaining a pest-free environment and ensuring nonfood-contact surfaces are cleaned regularly.
Inappropriate Language in Resident Care Order
Penalty
Summary
The facility failed to ensure a resident was referred to with dignity, as evidenced by the use of potentially derogatory language in the resident's care order. The resident, who was admitted to the facility with severely impaired cognition and required substantial assistance for activities of daily living, had an order entered by an LPN that used the term 'feeder' to describe the assistance needed for meals. This term was deemed inappropriate by both the LPN and the Director of Nursing, who confirmed that the order should have used language such as 'assist with all meals' or 'one to one assist with all meals'. The facility's policy on dignity emphasizes treating residents with respect and dignity, which was not upheld in this instance.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update a resident's care plan to reflect fall interventions after multiple incidents. A resident, identified as R10, was observed with a bruise around their right eye, which they explained was due to falling out of bed and hitting their face on a nightstand. The resident's environment was noted to be cluttered, and they reported that no measures had been put in place to prevent future falls. The resident had a history of falls, with incidents recorded on three separate occasions due to self-transfer, yet the care plan had not been revised since May 2023. The Director of Nursing acknowledged that the necessary steps were not completed after the resident's falls. The facility lacked a specific policy for revising care plans post-fall, although their Fall Prevention policy required a review and update of the care plan following a fall. The resident's medical record indicated a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, with intact cognition and a need for assistance with daily activities. Despite these needs and the history of falls, the care plan had not been updated to address the risk factors and environmental hazards effectively.
Failure to Consistently Apply Hand Splints for Resident
Penalty
Summary
The facility failed to apply hand splints for a resident, identified as R38, who was observed multiple times without the necessary hand splints in place. R38 was seen lying in bed with contracted hands and the hand splint was observed on the nightstand rather than on the resident. This occurred on several occasions, including when R38 was in a wheelchair in the dining room, where only one hand splint was applied, and the resident was observed eating with difficulty. R38's medical record indicated a diagnosis of Alzheimer's disease with severe cognitive impairment, and physician orders specified the use of lambs wool and gel splints to be worn at all times except for hygiene purposes. Interviews with facility staff, including an LPN, the Physical Therapy Director, and the Director of Nursing, confirmed that the hand splints should be consistently applied and only removed for hygiene. The facility's policy on assistive devices emphasized the importance of proper and consistent use of such devices to maintain or improve function and dignity. Despite this policy, the facility did not ensure the consistent application of the hand splints for R38, leading to a deficiency in care.
Failure to Date Opened Biologicals in Medication Carts
Penalty
Summary
The facility failed to ensure that biologicals were dated when opened, as observed in three medication carts. On December 8, 2024, a glucose test strips container was found undated in the A medication cart with an LPN. Similarly, the D medication cart contained an open and undated vial of Lantus insulin, a vial of Humalog insulin, a container of glucose test strips, and two latanoprost eye droppers. On December 9, 2024, the C medication cart was found with an undated Humalog insulin vial, three artificial tears eye dropper vials, and a glucose test strips container. During an interview on December 10, 2024, the DON confirmed that glucose test strips and insulin vials should be dated when opened, with glucose strips being valid for thirty days post-opening. The facility's policy mandates that all medications be stored according to the manufacturer's recommendations, ensuring proper conditions and security. The prescriber information for Lantus, Humalog, and latanoprost specifies storage guidelines, including the duration for which they remain usable once opened. The failure to date these biologicals upon opening indicates a lapse in adherence to these guidelines.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to ensure that food was served in a palatable and presentable manner for three residents. One resident, who was a newer admission for rehabilitation, expressed dissatisfaction with the taste and variety of the food, stating it was their main concern as they could barely eat their meals. Another resident reported that the food was horrible, specifically mentioning that the eggs tasted like they were powdered and the bread was old and hard. A third resident described the food as terrible, noting that the grits were solid enough to be lifted with a fork and that the French toast was often cold. This resident also criticized the presentation of the food, stating that the meat sometimes tasted old and the gravy was insufficient. The facility's dietary staff acknowledged the residents' complaints, with a kitchen staff member confirming that scrambled eggs were made from a liquid egg product, which some residents compared to powdered eggs. The Dietary Manager and District Manager explained that the chicken pot pies were made in a large bowl with biscuits baked on top, which differed from the whole pies previously served. The facility's Nutritional Services policy did not address food palatability, resident preferences, or presentation, and the Nursing Home Administrator and Director of Nursing indicated that these concerns should be addressed by dietary management staff.
Failure to Provide Non-Allergenic Food to Resident
Penalty
Summary
The facility failed to provide non-allergenic food to a resident, R13, who has a documented seafood allergy. On the evening of 12/09/24, R13 was served Shrimp [NAME] for dinner, which they mistakenly believed was Chicken [NAME]. Upon realizing the error, R13 experienced a tingling sensation in their mouth and tongue, indicative of an allergic reaction, and immediately spit out the food. A Certified Nurse Assistant (CNA) present at the time notified the Licensed Practical Nurse (LPN) S, who administered Benadryl to R13. Despite the incident, there was no documentation of the allergic reaction in R13's medical records, including progress notes, assessments, or orders. The facility's dietary management confirmed that R13's seafood allergy was clearly marked on their meal ticket, and it was the responsibility of both the cook and dietary staff to ensure meals were served according to these designations. However, the incident was not communicated to the Assistant Director of Nursing (ADON) or documented in the medical records, indicating a lapse in communication and documentation protocols. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the incident, acknowledging the occurrence and the resident's reaction. The facility's Nutritional Management policy, dated 1/2024, mandates that food allergies and intolerances be identified and noted on tray cards, which was not adhered to in this case.
Failure in Infection Control and PICC Line Management
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident, identified as R346, who was observed with a sign on their door indicating contact precautions due to an infection in their dialysis access site. Despite the sign, multiple staff members, including a respiratory therapist, a certified nurse assistant, a social worker, and a nurse practitioner, were observed not adhering to the required precautions. These staff members either did not wear the necessary personal protective equipment (PPE) such as gowns and gloves or failed to perform hand hygiene after providing care to R346. The Director of Nursing confirmed that R346 was on transmission-based precautions for C. auris and that all contact with the resident required PPE. Additionally, the facility failed to ensure timely dressing changes for a peripherally inserted central catheter (PICC) line for another resident, identified as R25. The resident reported having a PICC line in their right upper arm, with a dressing dated 12/2/24, which had not been changed as per the physician's order. The dressing was supposed to be changed every seven days, but records showed that eight different nurses documented monitoring the site without changing the dressing. The Director of Nursing confirmed that the PICC line should have been discontinued after the completion of antibiotics and that the dressing should be changed weekly. The facility's policies on infection prevention and control, as well as vascular access management, were not adhered to, leading to these deficiencies. The infection prevention policy required staff to follow transmission-based precautions and use PPE as per CDC guidelines, while the vascular access management policy required dressing changes every five to seven days. The failure to comply with these policies resulted in the observed deficiencies in infection control practices and PICC line management.
Deficiencies in Hygiene and Meal Assistance
Penalty
Summary
The facility failed to provide adequate hygiene care for a resident who had not received a shower in over a month. The resident, who was incontinent, non-ambulatory, and required assistance with bathing, reported that despite being scheduled for showers twice a week, they were not offered or were told it could not be done. The facility's records showed only two documented instances of showers being offered and refused, with no additional showers documented over a period of several weeks. The Director of Nursing confirmed that the resident should have been offered showers twice weekly and as needed, in accordance with the facility's policy on activities of daily living. Another deficiency was identified in the facility's failure to provide meal assistance to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident was observed multiple times with uneaten meals and nutritional drinks left untouched, despite having a physician's order for 1:1 assist feeding due to their inability to self-feed. The resident's care plan indicated a need for assistance with activities of daily living, including eating, and highlighted the resident's nutritional risk due to poor appetite and failure to thrive. Despite this, the resident was not consistently provided with the necessary assistance during meals, as observed by surveyors. The facility's policy on activities of daily living stated that residents who are unable to carry out these activities should receive the necessary services to maintain good nutrition and hygiene. However, the observations and interviews conducted during the survey revealed that the facility did not adhere to this policy, resulting in deficiencies in both hygiene care and meal assistance for the residents involved.
Failure to Apply Lymphedema Wraps and Reposition Resident
Penalty
Summary
The facility failed to apply lower extremity lymphedema wraps for a resident diagnosed with heart failure and bilateral lower extremity swelling. The resident reported that their legs had not been wrapped for edema for two consecutive days, despite a physician's order to wrap the legs daily. Observations confirmed that the resident's legs were not wrapped on multiple occasions, and the resident expressed concern about increased swelling affecting their therapy progress. The Director of Nursing acknowledged that the wraps should be applied daily as ordered, and the facility's policy mandates that care and services be provided according to accepted standards of clinical practice. Additionally, the facility failed to reposition another resident who was unable to reposition themselves due to severe cognitive impairment and a stage 2 wound on the coccyx. The resident was observed lying in bed in the same position over several days without a positioning wedge, which was necessary for their care. Interviews with staff confirmed that the resident required extensive assistance with activities of daily living and needed to be repositioned every two hours. The Director of Nursing confirmed that the resident should have a positioning wedge and be repositioned regularly, as outlined in the facility's policy on activities of daily living.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to provide adequate tube feeding and hydration for a resident who was observed multiple times without their tube feeding connected. The resident's tube feeding bottle was dated two days prior and was not infusing, despite physician orders for continuous feeding and water flushes. The resident, who had intact cognition, reported feeling hungry, and the Licensed Practical Nurse confirmed the feeding was not administered as ordered. The Registered Dietician emphasized the importance of adjusting feeding orders to meet caloric needs, and the Director of Nursing confirmed the resident should have received the feeding as prescribed. Another deficiency was identified in the facility's failure to provide meal assistance and nutritional supplements to a resident with severe cognitive impairment. The resident was observed with uneaten meals and without the prescribed nutritional supplements. Despite physician orders for 1:1 feeding assistance and nutritional shakes with meals, the resident did not receive the necessary support. The resident's weight had decreased, and the Registered Dietician confirmed the need for nutritional supplements three times a day. The facility's policies on enteral feeding and nutrition management were not followed, leading to these deficiencies. The policies outlined the need for adherence to physician orders and the involvement of a Registered Dietitian in assessing and meeting residents' nutritional needs. However, the observations and interviews revealed a lack of compliance with these policies, resulting in inadequate nutrition and hydration for the residents involved.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, leading to a deficiency. The resident, who had a history of witnessing a traumatic event, was issued an involuntary discharge notice without prior awareness, which triggered a traumatic reaction. The discharge plan involved sending the resident to a homeless shelter, which escalated their behavior, resulting in verbal aggression and threats. The facility's social services notes confirmed the lack of prior notification and the resident's refusal to sign the discharge notice. The resident's care plan, initiated months earlier, did not include any interventions to identify or address triggers related to their PTSD. The care plan only included general interventions such as educating the resident on expressing feelings and providing reassurance of a safe environment. There was no documentation of a PTSD assessment or identification of specific triggers and effective interventions in the resident's social services assessments or behavioral logs. Interviews with facility staff, including the Nursing Home Administrator and social services personnel, revealed a lack of awareness of the resident's PTSD diagnosis until after the incident. The facility's policy on trauma-informed care emphasized the importance of identifying triggers and implementing individualized care plan interventions, but these were not in place for the resident. The facility acknowledged the deficiency in documentation and the need for improvement in addressing the resident's trauma-related needs.
Failure to Reposition Resident with Pressure Wound
Penalty
Summary
The facility failed to ensure timely repositioning of a resident with a known pressure wound, leading to a deficiency in skin care management. On multiple observations throughout the day, the resident was found lying on their back without any repositioning or use of pillows to offload pressure from the sacral wound, despite the care plan indicating the need for routine repositioning and assistance with bed mobility. The resident, who has paraplegia and heart failure, was admitted with a stage three pressure ulcer and requires substantial assistance to reposition. The facility's policy on wound prevention and management emphasizes the importance of redistributing pressure for residents at risk of pressure injuries. However, the observations revealed that the resident was not repositioned every two hours as expected, and no devices or pillows were used to alleviate pressure on the sacral wound. The resident reported experiencing constant pain from the wound, and the Director of Nursing acknowledged the expectation for repositioning every two hours, which was not met.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R705, who was observed multiple times throughout the day with a soaked incontinence pad and wet bedding. Despite the presence of clean linens and briefs at the foot of the bed, the resident remained unchanged from the morning until the afternoon. The resident, who has Alzheimer's Disease and Bilateral Lower Extremity Contracture, was unable to recall when they were last changed and could not clearly express their feelings about being wet for an extended period. The Certified Nurse Assistant (CNA) responsible for R705's care confirmed that the resident was only changed once in the morning, around 7-7:30 AM, and not again until 2 PM. The Director of Nursing (DON) acknowledged that this was not acceptable, as the facility's policy requires checks and changes approximately every two hours and as needed. The facility's policy on Activities of Daily Living emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to carry out these activities themselves.
Failure to Follow Hospital Discharge Instructions
Penalty
Summary
The facility failed to adhere to hospital discharge instructions and orders for a resident diagnosed with Multiple Myeloma, who was cognitively intact and required moderate to maximum assistance for Activities of Daily Living. The discharge instructions included scheduling follow-up appointments with specialists in medical oncology, family medicine, and neurological surgery, as well as an outpatient MRI. However, only the medical oncology appointment was scheduled, and there was no documentation indicating that the resident attended any of the scheduled appointments. Interviews with facility staff revealed that the resident or their daughter canceled the initial oncology appointment, and subsequent appointments were rescheduled but not documented as attended. The Assistant Director of Nursing acknowledged the lack of documentation and mentioned that the staff member responsible for scheduling appointments was no longer employed at the facility. The Nursing Home Administrator noted concerns about transportation arrangements for the resident, who preferred to be transported by stretcher but did not meet the criteria. The facility's Physician Orders policy outlines the responsibility to maintain a schedule of diagnostic tests and consultations, and to arrange transportation for off-site services, which was not adequately followed in this case.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, who was initially admitted with diagnoses including End Stage Renal Disease, Type II Diabetes Mellitus, Morbid Obesity, and Hypertension, was cognitively intact and dependent on staff for transfers and toilet use. An incident occurred where the resident threw a feces-filled washcloth at a CNA, leading to the involvement of the police and the resident being sent to a local hospital for psychiatric evaluation. Despite being medically and psychiatrically cleared to return, the facility refused to accept the resident back, citing a lack of staff to care for him due to his aggressive behavior and non-compliance with care. The facility's Director of Nursing reported that the resident had a history of aggressive behavior towards staff, including hitting and belittling them, and often refused care while complaining about unmet needs. The facility's refusal to readmit the resident was based on these behavioral issues and the claim that they could not meet his needs. The facility's Transfer and Discharge policy outlines specific exemptions for discharge, including when a resident's needs cannot be met or when the safety of individuals in the facility is endangered. The facility's actions were based on these exemptions, as they claimed the resident's behavior endangered staff safety and that they lacked the resources to manage his care. An administrative hearing was scheduled to address the involuntary discharge.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R700, who was found missing from their room during a routine check by the midnight staff. The incident occurred outside the facility, and it was discovered that R700 had left the premises without any injuries observed at the time. The resident, who had a history of schizoaffective disorder and stroke, was noted to have severely impaired cognition and required assistance for all activities of daily living. The elopement was reported to the police, and the resident was returned to the facility without signs of distress or injury. Interviews with staff members revealed lapses in supervision and response to alarms. A Certified Nurse Assistant (CNA) assigned to R700 last saw the resident at approximately 9:30 PM and noted that an alarm had sounded after 10:00 PM. However, the alarm was turned off by another employee, and a food delivery was placed near the alarming door. Another CNA, who conducted a bed check at 11:45 PM, was unable to locate R700 and did not recall hearing any alarms prior to the discovery of the resident's absence. The facility's policy on elopement risk and missing residents, which requires care team members to know the location of residents and take appropriate action in case of a missing resident, was not effectively implemented. The Nursing Home Administrator reviewed the incident investigation, but the report indicates that the facility's procedures and processes for elopement were not revised following the incident.
Failure to Implement Timely Wound Care
Penalty
Summary
The facility failed to implement timely treatments for a newly identified wound for a resident, resulting in the worsening of the wound. The resident was admitted with diagnoses including cerebral infarction, dysphagia, and adult failure to thrive, and had impaired cognition with a mental status score of 7/15. Initially, the resident did not have any identified skin conditions. However, on January 14, 2024, a dime-sized open area was noted on the resident's sacrum, but no wound care treatment order was entered at that time. The wound progressed to a stage 3 pressure ulcer by January 26, 2024, measuring 1.0 cm x 1.0 cm x 0.1 cm, yet still lacked a physician's order for treatment. It was not until February 2, 2024, that a treatment order was documented. By July 11, 2024, the wound had worsened to 8.0 cm x 6.5 cm x 0.0 cm, remaining unchanged in stage. The Director of Nursing acknowledged that an order should have been entered at the time of the initial observation, as per the facility's policy to implement evidence-based interventions for residents at risk or with existing pressure injuries.
Failure to Honor Resident Self-Determination in LOAs
Penalty
Summary
The facility failed to honor the residents' rights to self-determination regarding Leave of Absences (LOAs), potentially affecting all 95 residents. The Nursing Home Administrator (NHA) implemented restrictions on LOAs, which included specific times residents could leave, activities that could restrict LOAs, weather-related restrictions, and the requirement for residents to be accompanied by a community member during LOAs. These restrictions were established after discussions with the medical director, law enforcement, local business owners, and community members due to concerns about resident behaviors in the community, such as panhandling and inappropriate conduct in local businesses. The LOA guidelines stated that residents could only sign out between 8 AM and 8 PM, and during inclement weather, they must be accompanied by an adult. Residents leaving outside these hours without accompaniment would face discharge against medical advice. The guidelines also prohibited residents from possessing cigarettes, lighters, weapons, marijuana, alcohol, or other intoxicants. The facility's Therapeutic Leave policy allowed residents to leave for non-medical visits in accordance with federal and state guidelines, but the new restrictions contradicted this policy. The Director of Nursing (DON) mentioned Medicaid insurance requirements but did not address the residents' rights.
Inconsistent Resident Council Meetings
Penalty
Summary
The facility failed to consistently assist the Resident Council in holding their monthly meetings, as identified during a mock survey. The Nursing Home Administrator (NHA) acknowledged the deficiency and presented a folder containing incomplete or undated resident council meeting notes. The facility's Resident Council policy emphasizes the importance of these meetings as a platform for residents to provide input on the facility's operations, discuss group concerns, and facilitate communication between residents and staff. The deficiency was partly attributed to the turnover of three Activity Directors within the past year, which contributed to the disorganization of the Resident Council meeting records. The facility's policy mandates that Resident Council meetings occur monthly, specifically every third Wednesday, with the participation of the president, residents, and the Activity Director. However, the review of the Resident Council minutes revealed missing dates and disordered records, indicating a failure to adhere to the policy and support the residents' rights to organize and participate in these meetings.
Lack of Qualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, potentially affecting all 95 residents. During an interview, the Nursing Home Administrator (NHA) revealed that a new Activities Director was hired last month, as there was no one in the position when he assumed his role. The Activities Director confirmed her start date as June 10, 2024, and an Activities Aide stated that since her start in April 2024, there had been no Activities Director. The Director of Nursing (DON) recalled that the last Activities Director was in place in March 2024. A review of the Activities Policy did not provide information regarding a qualified professional.
Elopement Incident Involving Resident with Schizoaffective Disorder and Vascular Dementia
Penalty
Summary
The deficiency reported in the survey pertains to the failure of a long-term care facility to provide adequate monitoring, supervision, and response to prevent the elopement of a resident identified as an elopement risk. The resident in question, identified as R901, had diagnoses including Schizoaffective Disorder-Bipolar Type, Anxiety Disorder, Violent Behavior, and Vascular Dementia. Despite being considered at risk for elopement and wearing a Wanderguard ankle bracelet, R901 managed to leave the facility undetected on the evening of 03/25/24. Staff only became aware of the elopement approximately eight hours later, leading to a significant delay in locating the resident. The facility's records indicated that R901's care plan included interventions such as redirecting the resident when wandering or exit-seeking and the use of a Wanderguard ankle bracelet. However, despite these measures, R901 was able to exit the facility without staff awareness. Interviews with staff members revealed discrepancies in their recollection of events, with some not recalling hearing any door alarms on the evening of the elopement. Surveillance footage from a nearby business indicated that R901 had been outside the facility for several hours before staff realized they were missing.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,184 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Livonia Woods Nursing And Rehabilitation | 0.5 mi | — | 0 | 0 |
| Regency At Livonia | 1.6 mi | ★★★★★ | 12 | 0 |
| Marywood Nursing Care Center | 2.5 mi | ★★★★★ | 5 | 0 |
| Fountain Bleu Health And Rehabilitation Center | 2.7 mi | ★★★★★ | 11 | 0 |
| Medilodge Of Livonia | 3.3 mi | ★★★★★ | 10 | 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.