Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Marywood Nursing Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness and hemiplegia, but intact cognition, requested hot soup that was heated in a foam cup by a CNA, who did not check the temperature with a thermometer despite facility expectations and posted guidance near the microwave. The CNA gave the soup with a straw, then left the room to obtain crackers and a different cup, during which time the resident accidentally spilled the hot soup onto their lap, causing redness to both thighs and later a second-degree burn blister on the right medial thigh. Nursing notes documented the immediate skin findings and subsequent development of a blister related to the hot liquid spill.
Two residents admitted after surgical treatment for femoral fractures did not have their hospital aftercare instructions, such as activity restrictions, sleeping positions, ice application, and limb elevation, incorporated into their care plans or physician orders. Nursing staff confirmed these instructions should have been entered and communicated, but this was not done, resulting in incomplete continuity of care.
A resident with heart disease, TBI, and moderate cognitive impairment repeatedly asked staff to go outside, but multiple staff members told the resident they could not go out and did not offer to take the resident outside at that time. The resident appeared frustrated and later asked an LPN, “What is this a prison,” after being denied again. The DON stated staff were expected to assist with the request or arrange a time to go outside, and the facility policy required residents to be treated with kindness, respect, dignity, and self-determination.
Confidential resident information was left visible on hallway devices and a report sheet. A laptop on a hallway cart was repeatedly observed open with a resident MAR displayed while the nurse was away or in a resident room, and a resident report sheet was also left face up on a portable computer station, exposing confidential information to visitors, staff, and passersby.
Hand hygiene was not completed during med pass for three residents. An LPN entered and re-entered a resident's room multiple times while giving meds and water without performing hand hygiene between glove changes, another LPN left and returned to a resident's room after the resident coughed and after giving an inhaler without observed hand hygiene, and an RN also exited a resident's room after administering pills and an inhaler without hand hygiene. The ICP and DON stated hand hygiene was expected, and the facility policy required staff to follow handwashing procedures.
A resident was discharged with an IV still in place despite physician orders for removal and incomplete documentation in the medical record. The only notes available were a refusal to remove the IV and a later statement that it had been removed, with no details on the procedure, date, or time, as required by facility policy. The deficiency was confirmed when a home health nurse found the IV still present after discharge.
A resident with intact cognition reported a foot injury during a transfer, but the LTC facility failed to report the incident to the state agency. Despite the resident's complaint of hearing a pop and experiencing pain, the initial assessment found no visible injury, and an x-ray later revealed fractures. The ADON and NHA confirmed the lack of a thorough investigation and absence of witness statements, leading to the deficiency.
A resident with intact cognition reported an injury during a transfer, resulting in fractures of the fourth and fifth metatarsal necks. The facility failed to conduct a thorough investigation, as there were no witness statements or staff interviews included in the report, and the incident was not reported to the state agency. The ADON and NHA acknowledged these deficiencies in the investigation process.
The facility failed to respond to call lights in a timely manner for several residents, with reports of delays exceeding 10 minutes, particularly during afternoon and night shifts. Residents expressed concerns about staff being on phones and insufficient staffing. Call logs confirmed extended wait times, contradicting the facility's policy of responding within five minutes.
A resident with severe cognitive impairment and malnutrition experienced a significant weight loss of 15.09% in less than 30 days, which the facility failed to address. Despite dietary progress notes indicating daily weight monitoring, this was not consistently done, and the issue was not brought to the dietician's attention. The DON admitted the weight loss was not discussed in the IDT meeting, and the facility's weight monitoring policy was not followed.
The facility failed to properly label and store medications, with unlabeled inhalers and eyedroppers found on medication carts, and medications left at the bedside for two residents. The facility's policy requires labeling with the date opened and secure storage, but these were not followed, as confirmed by nursing staff and the DON.
A staff member failed to don PPE when entering a resident's room under droplet precautions for Covid-19, despite clear signage and available supplies. The resident's medical record and facility policy required full PPE, confirmed by the Infection Control Nurse.
Failure to Safely Serve Hot Liquids Resulting in Burn Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely serve hot liquids, resulting in a second-degree burn blister for one resident. The resident had a history of muscle weakness and hemiplegia/hemiparesis following a cerebral infarction affecting the left non-dominant side, required staff assistance with bed mobility and transfers, and had intact cognition with a BIMS score of 14/15. On the day of the incident, the resident requested hot soup. A CNA heated the soup in a foam cup in the microwave for approximately 45 seconds and provided it to the resident with a straw. The resident then requested crackers and a spoon, and the CNA left the room to obtain a different style of cup from the kitchen to make the soup safer to eat with a spoon. During the CNA’s absence, the resident tipped the soup bowl over, accidentally spilling the hot soup onto their lap and the floor. A nursing progress note documented redness on the resident’s anterior thighs bilaterally immediately after the spill, and the area was cleansed with silicone cream applied per the resident’s wishes. The CNA confirmed they did not use a thermometer to check the soup temperature before serving it, despite the DON stating that thermometers and signage indicating appropriate hot liquid temperatures were available by every microwave and that staff were expected to obtain temperatures of hot liquids prior to serving them. Subsequent documentation identified a desiccated blister on the right medial thigh consistent with a second-degree burn from the hot liquid spill.
Failure to Implement After-Hospital Visit Care Instructions
Penalty
Summary
The facility failed to ensure that after-visit care instructions from hospital transfers were implemented for two residents who had recently undergone surgical interventions for femoral fractures. Both residents were admitted with specific aftercare instructions documented in their After Visit Summaries (AVS), including activity restrictions, sleeping positions, use of ice and elevation, and wearing compression stockings. However, upon review, there were no corresponding physician orders or care plan interventions addressing these instructions, such as sleeping precautions, ice application, or limb elevation. Interviews with nursing staff confirmed that such instructions should be entered into the care plan and physician orders, and that any treatments like ice or elevation would typically be documented in the Treatment Administration Record (TAR) or Medication Administration Record (MAR) after obtaining a physician's order. Further, one resident reported only occasionally receiving ice and was unaware of the need for leg elevation, indicating a lack of communication and implementation of the prescribed aftercare. Staff interviews revealed that the admitting nurse is responsible for entering aftercare instructions into the care plan and obtaining necessary physician orders, but this process was not completed. The Director of Nursing confirmed that AVS orders should be implemented and reflected in the care plan. The facility's policy requires comprehensive care plans to be developed with resident-specific interventions, but this was not followed for the residents in question.
Resident Requests to Go Outside Were Not Honored in a Dignified Manner
Penalty
Summary
The facility failed to ensure a resident’s requests were honored in a timely and dignified manner when R135 repeatedly asked to go outside and was told by multiple staff members that they could not go out. On 09/09/2025, R135, who was dressed and seated in a wheelchair, self-propelled into the common area and asked how to get to the front door because they wanted to go outside. An unidentified female staff member in blue scrubs told the resident they could not go outside and said the nurses needed to know where R135 was and that the resident would have to notify the nurse or get activities to help them. Staff E then told R135 they could not go outside and offered to take them back to their room. R135 appeared frustrated, turned around, and headed back toward their room. When R135 later asked LPN D to go outside, the nurse replied they could not go outside, and when R135 asked, “What is this a prison,” the nurse, while walking away, turned slightly and said, “almost.” None of the staff members offered to take R135 outside at that time. R135 had been observed the day before wheeling themselves around the facility onto different units. The resident’s record showed admission with diagnoses including heart disease and traumatic brain injury, and the active care plan documented moderate cognitive impairment with a BIMS score of 11/15 and a self-care performance deficit requiring limited assistance with toileting, transfer, and bathing; mobility was documented as wheelchair. Staff E later stated residents were not allowed to go out front alone but could go into the courtyard in the summer months, and that activities usually took residents out. The DON stated the expectation was that staff would assist the resident with their request or arrange a time to go outside. The facility policy on Resident Rights stated employees would treat all residents with kindness, respect, and dignity and included the resident’s right to self-determination.
Confidential Resident Information Left Visible on Hallway Devices and Report Sheet
Penalty
Summary
The facility failed to secure confidential medical records for one resident, R139, when a laptop on the B300 hallway cart was repeatedly observed open with the resident’s Medication Administration Record (MAR) visible. On 9/8/2025 at 8:30 AM, the laptop was open and visible on the hallway cart with the MAR displayed, and the nurse was not observed in the hallway or near the cart. On 9/9/2025 at 8:58 AM, the same laptop was again observed open with MAR information visible, and RN A was not observed in the hallway or near the cart. Later on 9/9/2025 at 11:15 AM, the laptop on the B300 hallway portable cart was again observed open with patient MAR information visible while RN A was in a patient’s room. RN A acknowledged the screen was unlocked and stated they would close it when they walked away. At 1:27 PM the same day, the laptop was again observed open with R139’s MAR information visible while RN A was in a patient’s room. In a separate observation on 09/10/25 at 7:50 AM, the P wing resident report sheet containing confidential resident information was left face up on the portable computer station outside room P213, exposing the information to visitors, staff, and passersby. LPN H later confirmed the report sheet should not have been left face up.
Hand hygiene not completed during medication administration
Penalty
Summary
The facility failed to ensure hand hygiene was completed during medication administration for three residents observed during the med pass. On 09/09/2025, an LPN checked vital signs for one resident, prepared medications, and entered the room with gloves on to administer them. When the resident needed additional water for milk of magnesia, the LPN returned to the medication cart, doffed gloves, poured water, donned new gloves, and re-entered the room without performing hand hygiene. The same sequence occurred again when the resident needed more water, and after completing the medication pass the LPN used hand sanitizer but did not rub it on all surfaces of the hands. The LPN acknowledged the need for sanitizer between glove changes. On 09/10/2025, another LPN prepared pills and an inhaler for a second resident. After the resident coughed following pill administration, the LPN left the room, retrieved a pulse oximeter, and returned without observed hand hygiene. The resident then received the inhaler and water to rinse the mouth, and the LPN exited again without hand hygiene. Later that morning, an RN prepared pills and an inhaler for a third resident. The resident self-administered the inhaler and was given water to rinse the mouth; the RN picked up the empty cup, returned it to the resident at the resident's request, took the inhaler back to the cart, and left the room without hand hygiene. The ICP stated hand hygiene should be completed when entering and leaving a patient's room and before moving on to another patient, and the DON indicated the expectation was that hand hygiene be completed. The facility policy titled Hand Washing/Hand Hygiene stated all personnel shall follow handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
Incomplete Documentation of IV Removal
Penalty
Summary
A deficiency occurred when the facility failed to maintain a complete and accurate medical record for a resident who was admitted with diagnoses including right knee effusion and syncope. The resident had a physician order to discontinue an intravenous (IV) line in the right arm, dated the day after admission. Progress notes indicated that the resident refused IV removal three times during one shift, and a subsequent skin assessment note stated that the IV had been removed. However, there was no documentation specifying the date, time, or details of the IV removal procedure in the resident's medical record. After discharge, a home health care admission assessment found the resident still had the IV in place, contrary to the facility's discharge documentation. The home care nurse, upon discovering the IV, was instructed by the primary care provider to remove it. The facility's Director of Nursing confirmed that there was no documentation beyond the initial notes regarding the IV's removal, and acknowledged that the expected documentation—such as date, time, resident tolerance, location, reason for removal, complications, and communication—was missing, as required by facility policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R700, who was involved in an incident during a transfer from a wheelchair to a bed. On the date of the incident, R700, who has a diagnosis of Spinal Stenosis and intact cognition, reported hearing a pop and experiencing pain in their right foot during the transfer. Despite the resident's complaint, the initial nursing assessment did not observe any swelling or bruising, and the incident was not reported to the state agency as required. An x-ray later revealed minimally displaced acute fractures of the fourth and fifth metatarsal necks. The Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) both confirmed that the incident was not reported to the state agency. The ADON acknowledged the lack of a thorough investigation and the absence of witness statements in the Incident and Accident (I&A) report. The NHA also confirmed that no staff interviews or statements were included in the investigation report. The failure to report the incident and conduct a comprehensive investigation led to the deficiency cited in the report.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R700, who reported an injury during a transfer from a wheelchair to a bed. The resident, who had intact cognition with a BIMS score of 15, reported hearing a pop and experiencing pain in their right foot during the transfer. An x-ray revealed minimally displaced acute fractures of the fourth and fifth metatarsal necks. Despite the resident's report and the x-ray findings, the facility did not conduct a thorough investigation into the incident, as evidenced by the lack of witness statements and the absence of a report to the state agency. Interviews with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) revealed that the incident was not properly documented or investigated. The ADON acknowledged the absence of witness statements and the lack of a thorough investigation, while the NHA confirmed that no staff interviews or statements were included in the Incident and Accident report. The NHA also confirmed that the incident was not reported to the state agency, as it was initially considered a known injury, despite the resident's inability to explain how the injury occurred.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for several residents, including two specifically identified residents and five anonymous residents, out of a total sample of 20. During a group meeting, multiple anonymous residents reported that certified nursing assistants (CNAs) on afternoon and night shifts were slow to respond to call lights, with some staff allegedly using their phones instead of attending to residents. The residents expressed that a reasonable wait time for call light response was 10 minutes, but they experienced longer delays, particularly during weekends. Call log reviews confirmed extended wait times, with numerous instances of call lights being activated for over 10 minutes, and in some cases, exceeding 20 minutes. Specific cases highlighted include a resident who waited an hour and a half to be changed after activating the call light, despite the facility's call log indicating shorter activation times. The Director of Nursing (DON) stated that the expectation was for call lights to be answered within five minutes, but acknowledged that the system does not differentiate between beds in a room, which could contribute to delays. The facility's policy on accommodating individual needs emphasizes maintaining residents' independence and dignity, but the reported delays in call light responses suggest a failure to meet these standards.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss for a resident diagnosed with Vascular Dementia, Severe Protein Calorie Malnutrition, and Heart Failure. The resident, who was severely cognitively impaired and required extensive assistance for certain activities, was independent with eating. Upon admission, the resident's weight was recorded at 104 pounds, with a history of a usual body weight of 130 pounds a year prior. Despite the resident's reported good appetite and the provision of Ensure three times a day, the resident experienced a significant weight loss of 15.09% in less than 30 days, which was not addressed by the facility. The dietary progress notes indicated that the resident's weight was to be monitored daily, but this was not consistently done. The dietician acknowledged the oversight, noting that the resident's intake was good and the issue of weight loss was not brought to her attention. The Director of Nursing admitted that the resident's weight loss was not discussed in the interdisciplinary team meeting, and the facility's weight monitoring policy, which defines a significant change in weight, was not adhered to. The facility's failure to monitor and address the resident's weight loss led to the deficiency.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility was found to have two deficient practices related to the labeling and storage of drugs and biologicals. The first deficiency involved the failure to label opened biologicals, inhalers, and eyedroppers with the date opened and a resident identifier. During a review of four medication carts, several instances were observed where medications such as Trelegy inhalers, Latanoprost eyedroppers, artificial tears, Moxicillin eyedroppers, and an Advair inhaler were not properly labeled. The facility's policy requires that all medications be labeled with the date opened, but this was not adhered to, as confirmed by the nursing staff and the Director of Nursing (DON). The second deficiency was related to the improper storage of resident medications, where medications were left at the bedside for two residents. One resident was found with a medication cup containing a white pill on their overbed table, which they consumed without knowing what it was. Another resident had two bottles of Flonase left on their bedside table. The facility's policy states that medications should not be left at the bedside, a point reiterated by the DON. Both incidents highlight a failure to ensure medications were stored securely and not left unattended, posing potential risks to resident safety.
Failure to Don PPE for Droplet Precautions
Penalty
Summary
The facility failed to ensure proper donning of Personal Protective Equipment (PPE) for droplet precautions for a resident diagnosed with Covid-19, Acute Kidney Failure, and Congestive Heart Failure. On a specific date, a staff member was observed entering the resident's room without wearing the required PPE to remove a lunch tray, despite the presence of a sign on the door indicating Droplet Transmission Based Precautions and a hanging drawer with necessary equipment and supplies for donning PPE. The resident's medical record indicated that they were on droplet contact precautions due to a Covid-19 diagnosis, with a physician's order specifying full droplet and contact precautions every shift. An interview with the Infection Control Nurse confirmed that full PPE should be worn when entering a resident's room under such precautions. The facility's policy on Transmission Based Precautions, updated in July, outlined that masks, gloves, gowns, and goggles should be worn when entering rooms of residents with infections transmitted by droplets.
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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 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 | 1.9 mi | — | 0 | 0 |
| Majestic Care Of Livonia | 2.5 mi | ★★★★★ | 12 | 0 |
| Four Seasons Nursing Center Of Westland | 3.2 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Plymouth | 3.3 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Haggerty Road | 3.5 mi | ★★★★★ | 0 | 0 |
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