Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Medilodge Of Livonia during CMS and state inspections, most recent first.
Incomplete documentation of bladder scans after catheter removal led to a deficiency. A cognitively impaired resident with urinary retention had a physician order for bladder scans q6h, but the MAR showed multiple missed or undocumented scans over several days. The ADON later confirmed the scans were being measured but not documented, and the order had been entered incorrectly in the record.
Kitchen sanitation, maintenance, and cooling practices were deficient. Clean utensil bins had dried debris, the meat slicer blade had dried food buildup, a floor opening near the dish area held soiled standing water, and dust/soil was observed on ventilation and ceiling surfaces and on the AC unit. Wet stacked pans were stored on the clean rack, and potato salad made from room-temp ingredients was cooled improperly, remaining above safe temp limits before being discarded.
Poor Cleanliness and Maintenance of Linen, Laundry, and Shower Areas: Observations found debris in the nourishment room sink cabinet and drain, discarded items in the clean linen transfer bin, a missing cold-water handle at the laundry handwash sink, and worn rough shelving used for clean linen storage. Multiple SPA rooms had soiled shower bed mats, residue buildup, black/green/brown buildup on caulk, corroded heating unit edges, and a smeared shower chair seat. The facility record stated clean linens must be stored and transported to prevent contamination.
Two residents had tube feeding poles observed with a buildup of dried brown tube feeding liquid that remained in the same soiled condition on repeated checks. The UM and DON stated housekeeping was responsible for cleaning the poles, and the facility policy addressed cleaning and disinfecting medical devices and hardware.
A facility failed to develop and implement care planned interventions for two residents. One resident with hand contractures after an intracerebral hemorrhage was repeatedly observed in bed with both hands contracted inward without hand splints, and the care plan did not address the contractures or extremity impairments. Another resident with abnormal posture, lack of coordination, and difficulty walking had an unwitnessed fall, was care planned for a perimeter/scoop mattress, but the mattress was not in place when the bed was later observed.
Failure to provide effective pressure ulcer care for two residents with significant immobility and existing pressure injuries. One resident with cerebral palsy, contractures, and a chronic sacral wound was repeatedly observed in bed and in a Geri-chair without pressure-offloading devices or a specialty mattress, and the sacral wound was noted to be open and bleeding. Another resident with dementia and multiple heel and foot pressure injuries was observed with heels resting on wheelchair footrests and with repeated supine positioning in bed without pressure-offloading devices at the torso.
A resident with interstitial pulmonary disease and sarcoidosis had an active order for continuous O2 at 2 L/min via NC, but was observed in bed and later in a wheelchair without oxygen and with no oxygen equipment in the room. The MAR documented the oxygen order as administered multiple times, yet the resident stated they had not had any oxygen in more than six weeks, and the DON/ADON could not explain the discrepancy.
Medication error rates were not kept below 5 percent when an LPN administered two medications incorrectly for a resident, resulting in a 6.25 percent error rate. The LPN prepared and gave an incorrect dose of divalproex and an incorrect dose of calcium carbonate, and later stated more medication needed to be given. The facility policy required comparing the medication source with the MAR to verify the resident name, medication, form, dose, route, and time of administration.
Failure to Perform Hand Hygiene During Medication Pass: An RN was observed preparing and administering medications via a feeding tube to a resident without being observed performing hand hygiene during the medication pass. The RN handled the med cart, PPE, syringe, container, trash, and the resident’s feeding tube care, while the facility policy required hand hygiene before handling meds and before and after donning and removing PPE.
The facility failed to provide dignified care and timely assistance to residents during meal times. Observations showed residents being transported improperly in geri-chairs and experiencing delays in receiving meals and feeding assistance. The DON acknowledged the ongoing issues with the dining process for residents needing more assistance.
The facility failed to provide adequate bathing and personal hygiene care for several residents, resulting in deficiencies in ADL care. Residents with medical conditions requiring assistance did not receive scheduled showers or bed baths, and documentation was inconsistent. The DON acknowledged the need for improved documentation and adherence to facility policies.
The facility failed to ensure proper hand hygiene, as observed with a nurse preparing and administering medications without washing hands and a CNA assisting multiple residents without hand hygiene between contacts. The dining room lacked facilities for hand washing or sanitizing, contributing to the infection control deficiency.
A resident receiving hospice care was repeatedly observed with their call light out of reach, despite staff presence in the room. The resident, who had conditions including Anorexia and Cirrhosis, was unable to call for help when experiencing hip pain. The facility's policy requires call lights to be within reach, which was not adhered to in this case.
A resident with a right buttock wound did not receive wound care as per physician orders, which required cleansing and dressing twice daily. Observations revealed the dressing was not applied as ordered, and the Treatment Administration Record falsely documented completion of care. The resident, with age-related physical debility and myasthenia gravis, required assistance with personal hygiene and mobility. The facility's documentation policy was not followed, as missing documentation was noted, and the DON acknowledged issues with the order's frequency.
A facility failed to apply palm protector devices for a resident with a left hand contracture, leading to an unprotected palm and a wound caused by the resident's long, sharp fingernails. Despite physician orders for a foam roll during the day and a splint at night, the resident was observed without these devices. The DON confirmed the oversight, acknowledging that staff should have addressed the condition of the resident's hand and nails.
A resident with dehydration risk was repeatedly observed with their water cup out of reach, despite expressing a desire for access. The facility's care plan and hydration policy were not adhered to, and the DON was unaware of any clinical reason for the inaccessibility.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.41% for a resident. A nurse administered 400 mcg of folic acid instead of the prescribed 1 mg and failed to administer the prescribed cyanocobalamin (Vitamin B12) 1000 mcg. The facility's policy requires medications to be administered as prescribed by the attending physician.
A resident with severely impaired cognition and MASD on the buttocks did not receive consistent wound care as per physician's orders. The facility's TAR showed multiple missed or undocumented treatments, and staff interviews confirmed the lack of documentation. Despite requests, no further records were provided, indicating non-compliance with the facility's skin management policy.
A resident with a history of respiratory and cardiac issues experienced a change in condition, including weakness and lethargy. Despite staff concerns and the resident's deteriorating state, the facility did not transfer the resident to a hospital, opting instead for in-house treatment. The resident's condition was not adequately monitored, leading to their death. Interviews revealed a lack of communication and appropriate action among staff and the covering nurse practitioner.
A resident with multiple health issues experienced a significant change in condition, including hypotension and lethargy. The assigned LPN called EMS for a transfer, but the Nurse Practitioner intervened, and EMS left without the resident. The resident's family member was not informed of these events and noticed the resident's altered state during a visit. The facility failed to notify the resident's representative as required by policy.
Two residents in an LTC facility did not receive appropriate care due to failures in medication administration and wound care. One resident missed several doses of fast-acting insulin due to errors in transcription and communication, while another did not receive prescribed wound treatments. Staff interviews revealed issues with order transcription and monitoring, contributing to these deficiencies.
Incomplete Documentation of Bladder Scans After Catheter Removal
Penalty
Summary
The facility failed to accurately document completion of bladder scans after an indwelling catheter was removed for one resident who had been admitted with diagnoses including displaced oblique fracture of the shaft of the left femur, diabetes, and hypertension. The resident was cognitively impaired and required assistance from 1-2 people with activities of daily living. After the catheter was removed, the physician was contacted and ordered bladder scans every 6 hours for urinary retention, with instructions to contact the provider if the bladder volume was over 500 cc. Review of the resident’s record showed multiple missed or undocumented bladder scans in the December 2025 MAR, including missing scans on several days and no documented scans on others. An interview with the ADON confirmed that an audit later found the bladder scan order had been entered incorrectly in the medical record and that urine output had been measured but not documented. The ADON acknowledged the missing documented bladder scans, and the facility’s Medication Orders did not address documentation and ensuring physician orders are carried out per professional standards.
Kitchen sanitation, facility maintenance, and cooling deficiencies
Penalty
Summary
The facility failed to maintain food service sanitation and food safety practices in the kitchen. During observation, dried debris was seen at the bottom of two clean equipment utensil bins, and dried food debris was observed accumulated on the underside of the meat slicer blade. The Food Service Director stated the cooks were responsible for cleaning and sanitizing the clean utensil bins daily, and when the debris on the slicer blade was pointed out, the Food Service Director acknowledged seeing it. The kitchen physical environment was also observed to be in poor repair and not kept clean. A 2 x 2 opening in the tiled floor near the dishwashing area was filled with soiled standing water, and the Food Service Director stated it was where a pipe used to be and that it collected water when mopping. The wall air ventilation cover between the 3-comp sink and hood cooking area had dust and soil buildup, with speckled black and brown buildup on adjacent ceiling tiles in an area approximately 2' x 2'. The Director of Maintenance wiped the ceiling with a cloth and the buildup was removed. Later, the kitchen air conditioning window unit above the three-compartment sink was observed with an accumulation of dust and soil. Food handling and cooling practices were also deficient. Water droplets were observed in three stacked quarter pans on the clean equipment rack, even though the Food Service Director stated staff know to air dry pans and ensure there are no droplets before storing. Potato salad prepared from room temperature canned cooked diced potatoes and other ingredients was observed tightly wrapped in plastic wrap in a cooler with condensation inside, and its temperature was 56-57 F. The food was later moved into two shallow pans and loosely covered, and after five hours from preparation it measured 44 F. The Food Service Director stated it should be between 30-41 F at that time, and the potato salad was later discarded.
Poor Cleanliness and Maintenance of Linen, Laundry, and Shower Areas
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and to properly store clean and sanitary supplies. During observation on 03/18/2026, black debris was seen accumulated on the inside shelf of the cabinet under the sink in the nourishment room, and multiple straws were observed in the sink drain as a possible clogging factor. In the laundry room, the cold-water handle was missing from the handwash sink, and the Housekeeping Manager stated the cold water shut off valve could be used to adjust temperature and that a repair request was in the building maintenance electronic request system. An environmental tour with the Housekeeping Manager and District Manager also identified discarded items layered at the bottom of the clean linen transfer bin under the inside support floor, and the Housekeeping Manager stated the bin should be cleaned after every load. Additional observations found worn and rough wooden shelving used for clean linen storage in the A, B, and C halls. In the SPA rooms, the shower bed mat in A hall had wet linen on it, brown and white residue in the creases, white residue on the underside, and a brown semi-solid substance at the floor drain; a CNA stated the shower bed is used infrequently and did not look clean. Black spots, green buildup, and brown buildup were observed on caulk along the floor-wall juncture in SPA rooms B, C, and D halls. Further observation found dripping water from the center crease of a shower bed mat with brown residue, corroded panel edges on a heating unit in SPA room D hall creating sharp exposed surfaces, and a red/brown smear on the seat of a shower chair. The facility record for collection, sorting, handling, and transportation of soiled linens stated that clean linens should be stored to prevent contamination by dust, debris, or other soiled items and transported in designated containers that are regularly cleaned.
Soiled Tube Feeding Poles
Penalty
Summary
The facility failed to maintain the cleanliness of tube feeding poles for two residents, R1 and R4, whose rooms were reviewed for cleanliness. R4 was observed in bed asleep, and the resident’s tube feeding pole had a buildup of dried brown tube feeding liquid that remained unchanged on repeated observations. R1 was also observed in bed asleep, and the resident’s tube feeding pole had a buildup of dried brown tube feeding liquid that was observed in the same soiled condition on repeated observations. During an observation with the surveyor, the Unit Manager acknowledged the soiled tube feeding pole for R1 and stated that housekeeping was responsible for cleaning the poles. The DON also stated that cleaning the poles was housekeeping’s responsibility. The facility’s Resident-Patient Room Cleaning policy was reviewed and included a section addressing cleaning and disinfecting medical devices and hardware.
Care plans not implemented for contractures and fall prevention
Penalty
Summary
The facility failed to develop and implement care planned interventions for two residents reviewed for care plans. One resident was observed lying in bed on multiple occasions with both hands contracted inward toward the wrists without hand splints. The resident’s care plan did not include interventions for hand contractures or extremity impairments. The medical record showed the resident had been admitted, transferred to the hospital on 3/10/26, and readmitted with a diagnosis of nontraumatic intracerebral hemorrhage. The nursing readmission evaluation documented contracted upper and lower extremities and the use of lower extremity immobilizer boots, and the ADON stated the resident had not yet been screened by therapy after readmission and that therapy screening would start development of the care plan. Another resident was admitted with diagnoses of abnormal posture, other lack of coordination, and difficulty walking, was cognitively intact, and required two-person assistance with ADLs. After an unwitnessed fall, the incident report stated the resident was found on the floor between the bed and cupboard on the right side of the body, with the resident reporting the right leg got stuck in the bed sheet and balance was lost. The care plan identified the resident as at risk for falls/injury and included a perimeter/scoop mattress intervention, but the resident’s bed was later observed without a scoop/perimeter mattress in place. The ADON was asked about the missing mattress and did not provide an explanation.
Failure to Provide Effective Pressure Ulcer Care
Penalty
Summary
The facility failed to implement interventions to promote wound healing and prevent new ulcers from developing for two residents with pressure-related skin injuries. One resident had cerebral palsy, contractures of the knees and elbows, severely impaired cognition, and was dependent on staff for all activities of daily living, including rolling, transfers, and mobility. This resident had a chronic sacral wound documented as a stage 2 pressure injury, with a history of smaller open and bloody areas and surrounding purple and red maroon discoloration consistent with deep tissue injury. During multiple observations, the resident was found lying on the back in bed or seated in a Geri-chair with the head elevated, without pillows or other devices at the sides of the torso to offload pressure from the sacral area, and without a specialty or low air loss mattress in place. The resident’s knees remained flexed, the heels were near the buttocks, and staff described the position as normal for the resident. At one point, the sacral wound was observed to be open and bleeding. The second resident had dementia, a right heel pressure ulcer, muscle wasting and atrophy, and impaired mobility requiring substantial to maximal assistance for bed mobility and dependent transfers. The resident also had bilateral heel wounds and other pressure-related skin issues, including stage 4 pressure ulcers to the left lateral foot and right lateral foot, a stage 2 wound to the right medial calf, and moisture associated skin damage to the right gluteus. During observations, the resident was seated in a wheelchair with both heels resting on the front edge of the footrest without PRAFO boots in place, and later with one heel on the footrest and the other hanging over the edge. In bed, the resident was repeatedly observed with the head of the bed elevated and without a pillow or device at the sides of the torso to offload pressure. The resident was also observed with PRAFO boots in place at other times and with a low air loss mattress active. Record review showed both residents had care plans identifying impaired skin integrity and the need for turning and repositioning as needed. The wound care documentation for the resident with the sacral wound noted the wound had increased and decreased in size over time, with the 03/16/26 measurement larger than the prior week. The wound care nurse documented the sacral wound as a stage 2 injury, and the therapy director reported the resident’s knees were stuck in flexion and the resident was dependent for dressing, feeding, bed mobility, and log rolling. For the resident with heel wounds, the wound care note documented multiple pressure injuries and MASD, and the skin issue education included turning every 2 hours. The facility policy stated that residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.
Failure to Maintain Current Oxygen Order and Use
Penalty
Summary
The facility failed to maintain a medical record that reflected a resident’s current status for oxygen use. R86 was admitted with diagnoses of Interstitial Pulmonary Disease and Sarcoidosis of the Lung, was cognitively intact, and required two-person assistance with activities of daily living. The resident had an active order dated 12/22/25 for oxygen at 2 L/min via nasal cannula continuously every shift for Sarcoidosis of the Lung, with instructions to notify the MD if SpO2 was less than 92%. During observation on 3/17/2026, R86 was in bed and was not receiving oxygen via nasal cannula; no oxygen concentrator or tank was present in the room. On 3/18/2026, the resident was again observed sitting in a wheelchair without oxygen and with no oxygen equipment in the room. The MAR showed the oxygen order was documented as administered 51 times between two shifts in February and 31 times between two shifts in March. On 3/19/2026, the Unit Manager asked R86 about the lack of oxygen, and the resident stated they had not had any oxygen in more than six weeks. The ADON was asked about the oxygen order and did not provide an explanation, stating she would contact the doctor for clarification.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication error rates were not kept below 5 percent when two medication doses were administered incorrectly out of 32 opportunities for one resident, resulting in a 6.25 percent error rate. On 03/18/2026 at 8:57 AM, an LPN prepared six medications for R97 and was observed giving an incorrect dose of divalproex sodium 125 mg delayed release oral capsules, with only one 125 mg capsule placed in the medication cup despite the order for six capsules for a total dose of 750 mg. The LPN also prepared calcium carbonate incorrectly, placing one 500 mg tablet in a medication cup even though the order documented one 750 mg chewable tablet. The medications were administered to R97, and when the orders were reviewed afterward, the LPN stated, "I need to give more." On 03/19/2026, the ADON reported there was a performance improvement plan related to the number of new nurses hired, and stated they had heard about the incorrect calcium carbonate dose but not the divalproex. The facility policy required comparing the medication source with the MAR to verify the resident name, medication, form, dose, route, and time of administration.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to perform timely hand hygiene during a medication pass for one resident who received medications via a feeding tube. On 03/18/2026 at 9:57 AM, an RN moved the medication cart to the opposite hall, prepared three medications for the resident, crushed two medications, and carried them to the resident’s room. The RN placed the medications on a gown disposal bin, donned a gown and gloves, then moved the medications to the tray table. After noting there was no water container available for administration, the RN removed the gown and gloves, exited the room, walked past hand sanitizer stations to the supply area, returned with a container and syringe, and re-entered the room after donning a gown and gloves again. The RN filled the container with water from the sink and administered the three medications, water, and a carton of liquid nutrition through the feeding tube inserted into the abdomen. The RN then rinsed the syringe and container at the sink, doffed the gown and gloves into the trash, gathered the trash bag, exited the room, returned to the medication cart, unlocked it, and took the trash to the soiled utility room. During the observation, the RN was not seen performing hand hygiene, and when questioned stated hand hygiene had been done after the trip to the soiled utility room. On 03/19/2026, the ADON stated hand washing for twenty seconds should occur before, during, and after care involving a feeding tube, urinary catheter, or wound. The facility policy stated hand hygiene is required before preparing or handling medications and before and after donning and removing PPE, and that gloves do not replace hand hygiene.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to ensure treatment and services were provided in a dignified manner for eight residents. Observations revealed that a resident was transported in a geri-chair facing backward, contrary to the proper procedure of facing forward. The CNA involved admitted to not being instructed to transport residents in this manner. Additionally, during meal times in the Rainbow dining room, several residents were observed not receiving timely assistance or meals. Some residents were left unattended with meal trays in front of them, while others were not served meals simultaneously, leading to delays in feeding assistance. The dining room observations highlighted a lack of adequate staffing to provide necessary one-to-one feeding assistance and cueing. Residents were left with unopened meal items, and CNAs were observed leaving residents in the middle of meals to attend to others. The Director of Nursing acknowledged these concerns and indicated that the dining process for residents requiring more assistance was an ongoing issue. The facility's policy emphasizes treating all residents with kindness, dignity, and respect, which was not upheld in these instances.
Deficiencies in Resident Hygiene and ADL Care
Penalty
Summary
The facility failed to ensure adequate bathing and personal hygiene care for six residents, leading to deficiencies in activities of daily living (ADL) care. Residents were not provided with the scheduled number of showers or bed baths, and documentation was inconsistent or lacking. For instance, one resident was scheduled for showers twice a week but only received a bed bath once in a 30-day period, with no documentation of hair care or facial hair removal. Another resident was observed with unkempt hair and facial hair, expressing a desire for assistance that was not provided. Several residents had medical conditions requiring assistance with personal hygiene, such as amputations, strokes, and cognitive impairments. Despite these needs, the facility's records showed that scheduled showers were often not attempted or documented as refused without proper documentation of the refusal. In some cases, residents were left in the same clothing for extended periods, contributing to poor hygiene and potential health risks. The Director of Nursing acknowledged the deficiencies, noting that residents scheduled for baths twice a week should receive them, and that staff needed to improve documentation of care attempts and refusals. The facility's policies on charting and documentation, as well as shaving, were not adhered to, resulting in inadequate communication and care for the residents' personal hygiene needs.
Failure in Hand Hygiene and Infection Control
Penalty
Summary
The facility failed to ensure proper hand hygiene during care for four residents, leading to potential infection control issues. Nurse 'C' was observed preparing medications for a resident without performing hand hygiene before or after the preparation and administration of medications. During the process, Nurse 'C' handled medication pills with bare hands, placing them back into the bottle, which is against the facility's hand hygiene policy. This lack of hand hygiene was observed multiple times as Nurse 'C' moved between the medication cart and the resident's room. Additionally, a Certified Nurse Aide (CNA) was observed in the dining room assisting multiple residents without performing hand hygiene between contacts. The CNA placed clothing protectors on residents and assisted with feeding without washing hands or using hand sanitizer. The dining room lacked a hand washing sink or hand sanitizing gel/foam dispenser, further contributing to the failure in maintaining proper infection control practices. The Director of Nursing acknowledged that hand hygiene should be conducted between resident contacts and that pills should not be touched with bare hands.
Failure to Maintain Call Light Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call light within reach for one resident, identified as R22, who was under hospice care with diagnoses including Anorexia, Cirrhosis of the Liver, and Diabetes Mellitus. On multiple occasions, R22 was observed lying in bed with the call light on the floor under the head of the bed, out of reach. Despite staff being present in the room to assist the resident, the call light remained inaccessible. On one occasion, R22 was found trying to call out for help due to hip pain, and confirmed they knew how to use the call light but did not have access to it. The Director of Nursing acknowledged the expectation that call lights should be within reach at all times, aligning with the facility's policy that mandates call lights be accessible to residents capable of using them.
Failure to Adhere to Wound Care Orders and Documentation
Penalty
Summary
The facility failed to complete wound care per the physician's order for a resident with a wound on the right buttock. The physician's order, dated January 7, 2025, specified that the wound should be cleansed with normal saline, triad applied, and covered with border gauze twice a day and as needed. However, observations on January 13 and 14, 2025, revealed that the dressing was not applied as ordered, and the resident reported that the cream for their buttocks wound was not applied as often as it should have been. The Treatment Administration Record (TAR) for January 14 and 15, 2025, falsely documented that the dressing change had been completed by the night shift nurse, although the dressing was observed to be unchanged from the previous day. The resident, admitted to the facility on October 23, 2024, had diagnoses including age-related physical debility and myasthenia gravis, with documented needs for assistance in personal hygiene and mobility. The facility's policy required treatments and dressing changes to be performed per physician orders, and all services provided to the resident should be documented in the medical record. However, a review of the December 2024 TAR revealed missing documentation for the right buttocks treatment, indicating a failure in adhering to the facility's documentation policy. The Director of Nursing acknowledged that the order should not have been written as twice a day unless specifically requested by the physician, and audits were being conducted to check for missing documentation.
Failure to Apply Palm Protector Devices for Resident with Hand Contracture
Penalty
Summary
The facility failed to ensure the application of palm protector devices for a resident with a left hand contracture, resulting in an unprotected palm from contracted fingers. Observations revealed that the resident was not using a splint or any protective device during the day, despite having a physician's order to apply a foam roll during the daytime and a splint at night. The resident's family member expressed concern about the potential for the resident's fingernails to cause a wound in the palm, which was confirmed by observations of a reddened, small open area on the palm. The resident's fingernails were noted to be long, discolored, with debris under the nail bed, and filed with sharp edges, contributing to the development of a wound. The Director of Nursing confirmed that the resident was supposed to have a splint at night and a foam roll or other device during the day to protect the palm. However, the resident was observed multiple times without these devices in place. The DON acknowledged that staff should have noticed the condition of the resident's hand and nails and addressed it. The facility's policy on restorative care emphasizes providing services to maintain the highest possible functional status, but this was not adhered to in the case of the resident's hand contracture and nail care.
Failure to Provide Accessible Hydration for Resident
Penalty
Summary
The facility failed to maintain a resident's water cup within reach, which is a deficiency in providing adequate hydration. The resident, who was receiving hospice care and had diagnoses including anorexia, cirrhosis of the liver, and diabetes mellitus, was observed multiple times with their water cup placed out of reach. Despite the care plan indicating a risk for dehydration and the need to encourage fluid intake, the water cup was consistently placed on a nightstand or over-bed table beyond the resident's reach. The resident expressed a desire to have the water cup within reach, but this need was not met. The Director of Nursing was informed of the issue and acknowledged there was no care-planned or clinical reason for the water to be inaccessible. The DON suggested that staff might have placed the water out of reach due to a history of the resident spilling water. The facility's hydration policy requires that fresh ice water be provided every shift and fluids offered every two hours for dependent residents, but these procedures were not followed in this case.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.41% for one resident. On January 14, 2025, at 8:20 AM, a nurse prepared and administered multiple medications to a resident, including an oral folic acid supplement. The nurse confirmed that all medications due at that time had been administered. However, upon reconciliation with the resident's physician's orders, it was discovered that the resident was supposed to receive 1 mg of folic acid, but only 400 mcg was administered. Additionally, the resident had an order for cyanocobalamin (Vitamin B12) 1000 mcg due at the 9 AM medication pass, which was not prepared or administered. The facility's policy states that medications should be administered as prescribed by the attending physician.
Failure to Document and Administer Wound Care
Penalty
Summary
The facility failed to ensure proper documentation and consistent treatment of a resident's wound care, specifically for Moisture Associated Skin Damage (MASD) on the buttocks. The resident, who had severely impaired cognition and was dependent on staff for various activities, had a physician's order for wound care that included cleansing, applying barrier cream, and covering with border gauze twice daily. However, the Treatment Administration Record (TAR) for August, September, and October 2024 showed multiple instances of missed or undocumented treatments on both day and night shifts. Interviews with the wound care nurse and the Director of Nursing (DON) confirmed the lack of documentation and acknowledged that some treatments might have been completed but not recorded. The wound care nurse described the wound as excoriation, likely caused by the resident's incontinence. A Certified Nursing Assistant (CNA) also reported observing the wound without a dressing and needing to clean it. Despite requests for documentation, no further records of the wound treatment were provided before the survey exit, indicating a failure to adhere to the facility's policy on skin monitoring and management.
Failure to Monitor and Treat Resident's Change in Condition
Penalty
Summary
The facility failed to provide ongoing monitoring and treatment for a resident, identified as R901, who experienced a change in condition. The resident, who had a history of acute respiratory failure, chronic obstructive pulmonary disease, diabetes, and heart failure, was observed with symptoms such as hand tremors, hypotension, general weakness, and lethargy. Despite these symptoms, the resident was not transferred to a hospital for further evaluation and treatment. Instead, the facility attempted to manage the resident's condition in-house, which ultimately resulted in the resident's death. Interviews with various staff members, including LPNs, RNs, and the Director of Nursing, revealed that there was a directive for EMS to leave without the resident, as it was believed the resident could be treated at the bedside. However, several staff members expressed concerns about the resident's declining condition and the decision not to transfer them to a higher level of care. The resident's physician and regular nurse practitioner were not present during the critical period, and the covering nurse practitioner, who was unfamiliar with the resident, did not contact the physician or order a hospital transfer. The facility's policy on change in a resident's condition did not address the need for ongoing monitoring and treatment, which contributed to the lack of appropriate care for the resident. The resident's family member, who visited during the period of decline, also noted the resident's unusual lethargy and lack of responsiveness. Despite these observations and the resident's deteriorating condition, there was no further documentation of treatment or monitoring after the initial assessment by the covering nurse practitioner.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for a resident who was admitted with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. The resident was cognitively intact, oxygen-dependent, and required assistance for transfers, toileting, and dressing. On a specific day, the resident exhibited symptoms such as noticeable hand tremors, hypotension, general weakness, lethargy, and difficulty speaking. Despite these changes, the facility did not promptly inform the resident's representative about the resident's deteriorating condition. The assigned nurse observed the resident's condition and initially called EMS for a hospital transfer due to the resident's low blood pressure and altered mental status. However, the Nurse Practitioner intervened, and EMS left without the resident. The resident's family member, who visited later that day, was not informed of the earlier assessment or the EMS call. They noticed the resident's lethargy and unclear speech and requested further evaluation from the Nurse Practitioner. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their physician, and their representative, which was not adhered to in this case.
Deficiencies in Insulin Administration and Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for two residents, leading to deficiencies in medication administration and wound care. Resident #2, who had multiple diagnoses including type 2 diabetes, did not receive fast-acting insulin as ordered due to a series of miscommunications and errors in medication transcription. The pharmacy's therapeutic interchange program led to changes in insulin orders, but the necessary blood sugar monitoring and insulin administration were not consistently carried out. This resulted in Resident #2 missing several doses of insulin and having elevated blood sugar levels without appropriate intervention. Resident #1, admitted with skin infections and multiple wounds, did not receive the prescribed wound care treatments as ordered. The medical record indicated discrepancies in the treatment orders, with some wounds not having documented care instructions. The Treatment Administration Record showed that wound care was delayed and not performed according to the physician's recommendations, leading to a lack of proper wound management for Resident #1. Interviews with facility staff, including the Unit Manager, Director of Nursing, and the Wound Nurse, revealed a lack of communication and oversight in ensuring that physician orders were accurately transcribed and followed. The pharmacy's role in entering orders into the electronic medical record and the facility's reliance on therapeutic interchange without proper monitoring contributed to the deficiencies observed in the care of both residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,234 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| The Manor Of Farmington Hills | 0.3 mi | ★★★★★ | 14 | 0 |
| Corewell Health Rehab & Nursing Center-commons Far | 1 mi | ★★★★★ | 15 | 0 |
| The Orchards At Redford | 2.1 mi | ★★★★★ | 20 | 0 |
| Regency At Livonia | 3.2 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Farmington | 3.2 mi | ★★★★★ | 23 | 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.