Below 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 Medilodge Of West Bloomfield during CMS and state inspections, most recent first.
Surveyors found that an LPN administered medications to multiple residents without performing required hand hygiene before each administration, contrary to facility policy. In addition, during a COVID outbreak affecting residents and staff, the Infection Preventionist’s respiratory surveillance line list was incomplete and did not clearly identify COVID as the pathogen, with missing collection dates, unspecified test types, absent symptom onset and symptom documentation, and no recorded resolution dates, and the infection map for that period did not indicate which residents had COVID, despite policy requiring thorough surveillance documentation.
The facility failed to ensure residents were treated with dignity and respect, particularly during the night shift. Two residents who were cognitively intact reported long delays in call light responses, difficulty obtaining toileting and brief changes overnight, and situations where staff acknowledged requests for bathroom assistance but did not provide timely care, resulting in residents using briefs instead of being toileted. A family member reported that CNAs did not assist a resident when the call light was used at night and that nurses administered nighttime medications very late, and also stated that grievance forms were not provided for nursing concerns and that the social worker did not follow up on issues. Resident council minutes over several months documented repeated complaints about rude and unprofessional behavior by nursing, aide, and cleaning staff, issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing them about incontinence. In a group interview, multiple residents stated that some aides and nurses did not treat them with dignity or show genuine care, while the DON reported being unaware of these dignity concerns.
The facility failed to maintain a clean, safe, and homelike environment in shared pantry and shower areas. Surveyors observed a leaking ice machine with black, mold-like substance on the pantry floor tiles and water-damaged cabinetry with similar black growth under a sink, which the maintenance supervisor acknowledged without prior cleaning or recognition of new damage. In shower areas, a bariatric shower chair had torn vinyl exposing foam, and a C/D unit shower room contained significantly pitched tile flooring, a torn and heavily stained shower curtain, heavy dark debris buildup on wall and floor tiles, chipped wall tiles, and missing corner caps exposing sharp metal and plastic edges. The DON stated they were previously unaware of these environmental conditions, despite facility policy requiring housekeeping and maintenance to maintain a sanitary, orderly, and comfortable environment.
A resident was sent to the hospital for vomiting and returned with antibiotic orders for a UTI, after which the facility documented a suspected healthcare-associated UTI and initiated two courses of antibiotics. The McGeer infection surveillance checklist for this resident was not completed, and a spreadsheet later indicated the resident did not meet McGeer criteria, yet antibiotics were continued based on the hospital diagnosis and a physician’s verbal preference, without documentation of that discussion. The Infection Control RN reported not reassessing residents after antibiotics were ordered and was unsure if physicians reassessed the need, despite facility policy requiring monitoring of response to antibiotics and review of outside antibiotic orders for appropriateness.
The facility failed to maintain a hazard-free environment related to resident smoking and smoking paraphernalia. Residents reported seeing vapes and smoking near the entrance, and surveyors observed smoking materials and smoke inside the building as well as a resident claiming a cigarette butt outside the main entrance. R3 had no smoking assessment despite a care plan for smoking and a history of vape use, R88 was observed with vape pens and had prior incidents of smoking in the room and bathroom without a smoking assessment or care plan interventions, and R5 kept cigarettes and a lighter on their person without a smoking assessment.
Expired medications were found in a medication storage cabinet during an observation with an RN. The expired items included liquid pain relief acetaminophen, glucosamine and chondroitin, and Vitamin B-6. The RN confirmed the expiration dates, and the DON stated central supply staff were responsible for maintaining medications in the storage rooms. The facility’s medication storage policy required medications to be stored according to the manufacturer’s recommendations.
Emergency Pull Cord Not Available in Shower Area: The facility failed to ensure an emergency pull cord was available within the immediate shower area for two shower stalls in the C/D shower room. Residents reported that staff sometimes stepped out of the shower room and that there was no pull cord in the shower area. The DON and Administrator confirmed the pull cord was only on the wall outside the stalls, about eight feet away, and the facility policy did not address call-light proximity in shower areas or if a resident was lying on the floor.
A resident with severe cognitive impairment and a documented full code status was found unresponsive by an LPN, who observed no vital signs and reported the resident as having passed. Believing the resident to be a DNR based on incorrect verbal information, staff did not initiate CPR or other life-saving measures, and an RN pronounced the resident deceased upon arrival. Only after another LPN checked the electronic record and discovered the resident was full code did the RN initiate the code protocol and start CPR. Interviews showed the initial LPN did not know the resident’s or any assigned residents’ code status or where this information was documented, despite facility policy requiring advance directive decisions to be documented and communicated to care staff.
A resident discharged back to the community with Medicaid-MI as the payor source experienced a delay in the facility’s notification to the state agency to switch coverage from nursing home level Medicaid to community level Medicaid. The business office, which is responsible for this task, did not submit the request until several weeks after discharge, despite the usual practice of completing it on or shortly after the discharge date. The Regional Business Office Manager reported that the delay was related to the prior business office manager leaving, and facility policy indicated that social services are responsible for assisting residents with financial matters as part of medically related social services.
Surveyors found that an LPN removed and administered Ativan from a controlled medication drawer without verifying the count or documenting the dose at the time of removal, instead delaying controlled substance documentation until after completing multiple residents’ morning medications, contrary to facility policy. In a separate case, a resident with chronic diastolic heart failure, stage 3 CKD, and severe cognitive impairment experienced a change in condition with lethargy and low BP; although the provider ordered STAT labs and IV hydration with 0.9% NS at 70 cc/hr for one liter and Q6H vitals, the IV order was transcribed with an incorrect start date for the following day, resulting in a delay in carrying out the ordered treatment.
The facility failed to provide adequate medically-related social services for two residents with dementia and mood disorders following resident-to-resident altercations and documented behavioral concerns. One resident had severe cognitive impairment and repeated verbal and physical aggression toward a roommate, while another had severe cognitive impairment, depression, and anxiety with episodes of yelling, verbal aggression, and distress over loss of autonomy. Social service assessments for both residents were incomplete, missing key information on mood, behavior, triggers, calming strategies, and psychoactive medication review, and required quarterly assessments were not completed. There was no documented social services follow-up after alleged physical and verbal assault, subsequent roommate conflicts, or psych notes describing significant psychosocial distress, despite facility policy requiring initial and quarterly assessments, identification of psychosocial needs, and ongoing monitoring.
A resident with a seizure disorder and severe cognitive impairment had an order for Valproic Acid via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. On the day in question, the morning dose was not actually given until 12:44 PM, far outside the allowed administration window, and the evening dose was not administered at all, despite MAR entries indicating it had been given. Nursing notes documented two seizures in the early morning hours following these missed and delayed doses. The DON confirmed the significant delay of the morning dose and the omission of the evening dose, in contrast to facility policy requiring medications to be given per physician orders and identifying time of administration and omission as medication error factors.
Failure to Provide NOMNC and SNFABN: The facility did not complete or provide required Medicare coverage notices for three residents reviewed for beneficiary notification. Record review showed missing NOMNC/SNFABN documentation, including a resident who remained in the facility after Medicare A coverage ended, leaving residents and/or representatives uninformed about potential private pay charges and unable to appeal.
Failure to Notify Ombudsman of Resident Transfer: A resident with CHF and COPD became extremely lethargic and confused, with low O2 sat on NC, and was transferred to the hospital by 911 after the NP ordered the transfer. Surveyors found no documentation that the transfer notice was sent to the State LTC Ombudsman’s office, and the Administrator and SW stated transfer/discharge notifications had not been completed for the requested period.
PASARR Level II evaluation was not available in the resident’s record on admission and was not reflected in the care plan or social service documentation. The resident had multiple psychiatric diagnoses, including bipolar disorder, borderline personality disorder, and mood disorder, and the prior facility’s Level I PASARR identified serious mental illness and psychotropic medications. The SSD later located and uploaded the Level II assessment, which recommended MH monitoring, therapy, psychiatric med review, psychiatric follow-up, and psychiatric consultation, but those recommendations were not documented in the resident’s plan of care.
A resident with a pacemaker and renal dialysis dependence missed a cardiology pacemaker follow-up because the appointment was not coordinated correctly. Staff gave conflicting explanations about whether transportation failed to arrive, paperwork was missing, or the appointment had been cancelled, and the legal guardian was not notified even though they traveled to meet the resident for the visit.
Failure to provide appropriate catheter care was identified for a resident with an indwelling catheter. The resident was observed with the catheter bag touching the floor, tubing taut and unsecured, and the resident reported pain from the tube pulling. On another observation, the drainage bag was crumpled in a privacy bag with cloudy urine unable to flow freely, and the nurse stated the resident did not have a catheter securement device. The resident had diagnoses including UTI and Bell’s Palsy, a BIMS score of 8, and an order for routine catheter securement device changes.
A facility failed to ensure 3 residents clearly understood the binding arbitration agreement and their right to refuse it. Two residents with BIMS 15/15 said they did not recall signing and would not have agreed if they knew it prevented disputes from going to a judge, jury, or trial; a third resident said the agreement was never explained that way and only recalled being told disputes under $20,000 would be handled in-house. The AD said residents were given a packet of documents and that the explanation of binding was not fully understood.
A resident with severe cognitive impairment and a history of multiple falls was not consistently provided with the one-on-one supervision required by their care plan. Despite repeated documentation of the resident's restlessness, impulsivity, and need for close monitoring, the facility removed the one-on-one sitter, leading to several falls with injuries. Facility administration acknowledged the inability to maintain the required supervision and failed to implement an adequate alternative plan, resulting in repeated incidents and harm.
A resident with severe cognitive impairment alleged being pushed from her wheelchair by staff and was subsequently hospitalized. Although the allegation was communicated to facility leadership and APS was notified by the hospital, the facility did not report the incident to the State Agency as required by regulation and facility policy, with the Administrator stating they believed the incident did not occur.
A resident with severe malnutrition, dysphagia, and recent amputation experienced a rapid weight loss of over 15 pounds within four weeks due to the facility's failure to consistently monitor nutritional status, obtain required weekly weights, and implement or adjust interventions despite ongoing poor intake and documented feeding difficulties. The resident's significant weight loss was not identified or addressed by the Registered Dietician until after transfer to the hospital for extreme weakness and refusal of food and fluids.
A facility did not conduct a comprehensive investigation after a resident alleged sexual abuse. The investigation was limited to interviews with the resident's responsible party and two male staff, omitting interviews with other staff present at the time, the nurse who documented the initial report, and other residents. The Administrator/Abuse Coordinator was unaware of an earlier report by the resident, and the investigation did not follow facility policy requiring statements from all relevant witnesses.
A resident with severe cognitive impairment and mobility deficits fell in the shower after a CNA attempted a solo transfer, despite the resident's request for assistance. The fall was not documented or assessed by staff at the time, and management, physician, and responsible party were not promptly notified. The incident was only reported later by the resident, and no timely investigation or complete post-fall assessment was conducted, contrary to facility policy.
A resident with multiple serious conditions experienced a decline, prompting a physician to order STAT CMP and CBCD labs. The facility did not obtain these STAT labs as ordered, with staff stating their contracted lab did not provide STAT services on the needed day, despite the contract allowing for such services. The resident's condition worsened, and the labs were not completed prior to the resident's transfer out.
A resident reported confusion and believed a man had been in her room, later alleging sexual abuse to hospital staff. The facility's investigation was limited to interviews with the resident's responsible party and two male staff, omitting interviews with other relevant staff and residents, and the Abuse Coordinator was unaware of the initial report. This did not meet the facility's policy for a thorough abuse investigation.
A facility failed to maintain an effective infection control program, as evidenced by mishandling a MRSA case. A resident with a positive MRSA culture reported inadequate room cleaning and lack of protective equipment use by staff. The facility lacked infection control data for several months, and the DON was unaware of the MRSA case. The facility's policy requires ongoing infection monitoring, which was not followed.
The facility failed to maintain the hot water supply for 82 residents due to both boilers failing and not undergoing required CSD-1 inspections. The Maintenance Director confirmed the lack of hot water and revealed that the necessary maintenance and inspection were delayed, with no action taken by the corporate office. The facility's preventive maintenance policy was not followed, resulting in non-compliance with the CSD-1 code.
A resident with diabetes developed a scalp blister, initially dismissed by the physician as common. The resident's dermatologist diagnosed it as MRSA, but the physician failed to document the diagnosis or treatment in the records. Despite orders for antibiotics and precautions, the physician's notes did not reflect the MRSA diagnosis, indicating a lack of thorough documentation and follow-up.
A resident in a facility was not provided adequate assistance with activities of daily living, including regular bathing and transfers. The resident was left waiting for two hours to be transferred to a wheelchair, and reported rarely receiving showers due to staff reluctance. The facility's documentation showed only two showers since admission, with no refusals documented, despite the requirement for twice-weekly bathing offers.
A facility failed to identify, monitor, and assess a resident's skin impairment, leading to a missed MRSA diagnosis. Despite the resident's consultation with a dermatologist and subsequent MRSA diagnosis, the facility did not document the skin condition or follow up on the diagnosis. The attending physician and nursing staff provided conflicting information, and the Director of Nursing was unaware of the MRSA diagnosis, indicating a significant deficiency in care and monitoring processes.
The facility failed to return residents' clothing in a timely manner, as reported by several residents during a council meeting. Missing items included shirts and pants, with grievances documented in past meetings. Staff interviews revealed that the issue often stemmed from unlabeled clothing bags, complicating the return process. The Administrator acknowledged the problem, noting some residents' reluctance to label clothing.
The facility failed to ensure safe medication storage, with loose, unidentifiable pills found in a medication cart and a refrigerator storing insulin lacking a thermometer and temperature logs. An LPN acknowledged these issues, and the DON was informed, recognizing the need for proper storage and temperature monitoring.
The facility failed to maintain clean storage of linens and resident clothing in the laundry room, resulting in contamination with dust and dryer lint. Two linen carts with clean laundry were found covered in thick white debris, and the facility lacked a clean laundry storage policy. Housekeeping managers confirmed the unhygienic conditions.
A resident with Chronic Obstructive Pulmonary Disease and Adjustment Disorder was verbally threatened by a CNA at the nurse's station. The CNA used inappropriate and threatening language, which was corroborated by witnesses. The facility terminated the CNA and re-educated staff on abuse and neglect policies.
Inadequate Hand Hygiene and Incomplete Infection Surveillance During COVID Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement infection control standards during medication administration and to maintain an effective infection control surveillance program. During a medication pass, an LPN was observed administering medications to four residents, including residents 9 and 65, without performing hand hygiene before each medication administration for each resident. This practice was inconsistent with the facility’s Medication Administration policy, which requires staff to wash hands prior to administering medications and to follow facility hand hygiene protocols. In an interview, the DON confirmed that nurses are expected to perform hand hygiene before and after each medication administration for each resident. The facility also failed to maintain complete and accurate infection surveillance documentation during a COVID outbreak in October 2025 that affected 13 residents and six staff members. The Infection Control RN produced a Respiratory Surveillance Line List for that period and verbally confirmed that the listed individuals had tested positive for COVID, but the document itself did not specify COVID as the pathogen. The line list contained multiple blank or incomplete fields, including missing dates of specimen collection, unspecified test types marked only as “Other,” missing or “N/A” symptom onset dates, blank symptom documentation columns, and pathogen fields marked as “Other” without specifying the organism. The outbreak symptom resolution dates were blank for all names, and the October 2025 facility infection map did not indicate which residents had COVID. These practices did not align with the facility’s Infection Prevention and Control Program policy, which states that the Infection Preventionist leads surveillance activities and maintains documentation of incidents and findings.
Failure to Ensure Dignified, Respectful Care and Timely Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly regarding toileting, incontinence care, and staff interactions. One resident with diagnoses including difficulty in walking, polyneuropathy, and primary insomnia, and a BIMs score of 15 indicating no cognitive impairment, reported that night shift staff were not responsive to toileting needs. This resident stated they were only changed once during the night around 11:00 PM–12:00 AM and not again until approximately 6:30 AM, and that when they used the call light at night, a CNA would enter, ask what was needed, turn off the call light, and leave without providing toileting assistance until morning, resulting in the resident using the restroom in their brief. Another resident, also cognitively intact with a BIMs score of 15 and admitted with diagnoses including urinary tract infection and muscle disorder, reported that when they used the call light, it took staff so long to respond that they forgot what they had requested, and that it was difficult to get their brief changed on the night shift. A family member of one resident reported to the state agency that CNAs did not help the resident when the call light was used at night and that nurses did not administer nighttime medications until after 11:00 PM. The same family member stated they believed grievance forms were only available for missing items and not for nursing concerns, and also reported that the social worker did not follow up on requests. Resident council minutes over several months documented repeated concerns about staff attitudes and professionalism, including cleaning staff being rude, nurses and aides not being professional, ongoing issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing the resident about incontinence. In a confidential resident council interview with eight residents, multiple residents reported that some aides and nurses did not treat them with dignity, stating that staff did not “have a heart for the people” and did not actually care. The DON later reported being unaware of these dignity concerns. These findings occurred despite a facility policy on promoting and maintaining resident dignity that requires respectful communication and acting upon resident preferences.
Failure to Maintain Clean and Safe Pantry and Shower Environments
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment in multiple common-use areas, including the upper-level pantry and shower rooms. Surveyors observed an ice machine in the upper-level pantry leaking water onto the floor, with a black, mold-like substance present on the floor tiles. The cupboard under the pantry sink showed visible water damage and a black, mold-like substance on the bottom shelf. The Maintenance Supervisor stated they planned to get a new ice machine but did not explain why the mold-like substance on the floor had not been cleaned, and further reported he had repaired a leak under the sink about a year earlier but was not aware of any new leak or current water damage. In the upper-level shower room near the nurse's station, a bariatric shower chair was observed with torn vinyl on the seat, exposing foam and creating a surface that was no longer smooth and easily cleanable. In the C/D unit shower room, surveyors and the DON observed two shower stalls with significantly pitched tiled flooring, a torn and heavily stained white vinyl shower curtain, and a heavy buildup of dark, blackish debris along the wall and floor tiles inside the shower area. The tiled shower room walls had several chipped tiles, and plastic corner coverings were missing caps at the top, exposing sharp metal and plastic edges. The DON reported being unaware of these conditions prior to the observation. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment and that unresolved environmental concerns should be reported to the Administrator.
Failure to Monitor and Evaluate Antibiotic Use per Stewardship Program
Penalty
Summary
The deficiency involves the facility’s failure to monitor and evaluate antibiotic use for a resident in accordance with its antibiotic stewardship program. The Infection Control RN reported that the resident was sent to the hospital after vomiting yellow-green emesis and returned the same day with antibiotic orders for a urinary tract infection (UTI). The facility’s Infection Report Form listed an onset date of 10/13/25, a suspected healthcare-associated UTI, and documented orders for Keflex 500 mg every six hours from 10/14/25 to 10/18/25, followed by Macrobid 100 mg twice daily from 10/17/25 to 10/22/25. A McGeer Criteria for Infection Surveillance Checklist was started for this resident, but the criteria section was not completed. The Infection Control RN provided a spreadsheet indicating that the resident did not meet McGeer’s criteria for UTI, yet the antibiotics were continued. When asked why antibiotics were continued if criteria were not met, the RN stated they followed the hospital’s UTI diagnosis and that the attending physician wanted the antibiotics continued, but there was no documentation of this discussion. The Infection Control RN also stated they did not personally reassess residents after antibiotics were ordered and was unsure whether facility physicians assessed the relevance of the antibiotic therapy. These actions and omissions conflicted with the facility’s written Antibiotic Stewardship Program policy, which required monitoring response to antibiotics to determine ongoing need or adjustments, and review of antibiotic orders from consulting, specialty, or emergency providers for appropriateness.
Unsafe Resident Smoking Practices and Unsecured Smoking Materials
Penalty
Summary
The facility failed to ensure an environment free from accident hazards related to resident smoking and the storage of smoking paraphernalia for three residents and multiple residents who participated in a confidential resident council interview. The facility’s smoking policy stated that smoking materials were to be kept secured in a designated area with limited staff access, that residents were not to keep smoking materials in their rooms, and that any resident with smoking privileges required direct supervision throughout the entire smoking period. However, the Administrator stated the facility was technically a non-smoking facility, while also acknowledging that residents were vaping and signing out on leave of absence to smoke, and that the facility had discussed changing smoking practices because it did not feel safe for residents to be on the sidewalk by the main road. During the resident council interview, several residents reported concerns about other residents being seen with smoking materials such as vapes and smoking near the entrance. One resident stated there were times they went outside in the summer and felt they could not because residents were smoking there. Survey observations also identified smoking paraphernalia and smoke inside the facility, and an unknown resident asked a surveyor to pick up a cigarette butt outside the main entrance/awning and stated it was theirs and intended to be smoked. The Administrator acknowledged the concern related to a resident vaping in the facility and stated that R3 had been observed with vape materials brought in by family, but no further explanation was provided regarding safe smoking oversight. R3’s record showed no smoking assessments to determine safe smoking ability, handling of smoking materials, or adaptive needs. The care plan stated the resident chose to smoke and included a goal for safe smoking in designated areas at scheduled times, but the Administrator reported there were no current designated areas or scheduled times. R3 was admitted with diagnoses including COPD, nicotine dependence, morbid obesity, multiple psychiatric diagnoses, and obstructive sleep apnea. R88 was observed with a vape pen in the room and a dissipating smoke cloud, and later with a black vape pen on the bed; the resident stated they sometimes used the vape in the room and sometimes went out of the facility to use it. R88’s record showed prior incidents of smoking in the bathroom and in the room, but no smoking assessment was completed and no care plan or interventions were implemented for vape use. R5 acknowledged being a smoker, stated cigarettes and a lighter were kept on their person, and reported no smoking assessment had been performed; the care plan only documented that the resident chose to smoke and to inform the resident or family of the smoking policy, designated areas, and storage of smoking materials.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired medications were found in one of the facility’s medication storage rooms during observation and record review. On 2/25/26 at 12:10 PM, the medication storage room on the ground floor was observed with RN E, and expired bottles dated 01/2026 were found in the medication storage cabinet, including liquid pain relief acetaminophen 160 mg/5 ml, glucosamine and chondroitin, and Vitamin B-6. RN E verified the expiration dates and stated the expired bottles should have been removed from the storage unit. The Director of Nursing later stated central supply staff were responsible for maintaining medications in the facility’s storage rooms and acknowledged the expired medications had been removed after the issue was identified. Review of the facility’s medication storage policy, revised 1/30/24, stated medications housed on the premises are to be stored according to the manufacturer’s recommendations.
Emergency Pull Cord Not Available in Shower Area
Penalty
Summary
The facility failed to ensure an emergency pull cord was available within the immediate shower area for two shower stalls in the C/D shower room. During a confidential resident council interview, several residents reported concerns about shower safety, including that staff sometimes stepped out of the shower room and that there was no pull cord in the shower area. On observation of the C/D unit shower room, the DON and later the Administrator confirmed that the two shower stalls did not have an emergency pull-cord in the vicinity, and the closest pull-cord was on the wall outside the shower stalls approximately eight feet away. The shower stalls were also observed to have significantly pitched tiled flooring. Review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated 12/28/2023, did not address the proximity of the call-light in shower areas or if a resident was lying on the floor.
Failure to Honor Full Code Status and Initiate Timely CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s full code advance directive by not initiating CPR or other life-saving measures when the resident was found unresponsive. The resident had diagnoses including Parkinson’s disease with dyskinesia and encephalopathy and had a BIMS score of 0/15, indicating severe cognitive impairment. When an LPN went to care for the resident at approximately 4:45 PM, the resident was observed unresponsive, with eyes open and fixed, mouth open, and no vital signs detected. The LPN then approached another LPN and reported that the resident had passed, inquired about the code status, and was told the resident was a DNR. Based on this information, no immediate resuscitative efforts were initiated. A supervising RN was called to pronounce death and, upon arrival, found the resident cool to the touch and not breathing, and pronounced the resident deceased. Shortly afterward, another LPN discovered in the resident’s profile that the resident was actually a full code. The RN then initiated the facility’s code protocol and started CPR only after learning of the correct code status. Interviews revealed that the LPN who first found the resident unresponsive did not know the resident’s code status, did not know where code status was documented, and did not know the code status of any assigned residents. The facility’s policy stated that decisions regarding treatment and advance directives were to be documented in the medical record and communicated to staff responsible for the resident’s care. The Administrator confirmed that, due to the unexpected death, the facility’s response to provide CPR and other life-saving measures was delayed.
Delay in Medicaid Status Change Following Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and timely discharge process for a resident whose Medicaid coverage needed to be transitioned from nursing home level to community level upon discharge. A complaint submitted to the State Agency alleged that the facility delayed notifying the Michigan Department of Health and Human Services that the resident had been discharged, which affected the resident’s ability to access community level Medicaid services. Record review showed the resident was admitted on an unspecified date and discharged back to the community on 8/1/25, with Medicaid-MI as the payor source at the time of discharge. During an interview, the Regional Business Office Manager explained that the facility business office is responsible for switching a resident’s Medicaid from nursing home level to community level, typically on the day of discharge, the next day, or by the end of that week. However, for this resident, the request to switch to community Medicaid was not submitted until 8/28/25, nearly four weeks after discharge. The Regional Business Office Manager attributed the delay to the prior business office manager leaving around that time. Review of the facility’s Social Services policy showed that the facility is responsible for providing medically related social services, including assisting residents with financial matters, to help them attain or maintain their highest practicable well-being.
Failure to Follow Controlled Substance Documentation Standards and Correctly Transcribe IV Hydration Order
Penalty
Summary
The deficiency involves failures in controlled substance administration and documentation, as well as incorrect transcription and implementation of a physician’s order. During a morning medication pass, an LPN prepared and administered Ativan 0.5 mg for a resident by removing one tablet from the locked controlled medication drawer and adding it to the resident’s other morning medications. The LPN did not verify the current Ativan count, did not document the dose removed on the controlled count sheet at the time of removal, and proceeded to prepare and administer medications for three additional residents without signing out the Ativan dose. When interviewed, the LPN stated they sign for controlled medications after completing all morning medication administrations and indicated that some nurses sign when removing the pill and others after finishing the medication pass. Facility policy on controlled substance administration and accountability requires that each dose administered be recorded, subtracted from the previous count, and the remaining amount documented. The deficiency also includes a failure to correctly transcribe and carry out a physician’s order for IV hydration for another resident with chronic diastolic heart failure, stage 3 chronic kidney disease, and severe cognitive impairment. A progress note documented that this resident was lethargic, difficult to arouse, with low blood pressure, but responsive to verbal stimuli and sternal rub, and with stable vital signs otherwise. The physician was notified and gave STAT orders for labs (CBC with diff, CMP, UA/urine culture), IV hydration with 0.9% normal saline at 70 cc/hr for one liter, and vital signs every six hours for 24 hours. However, the IV fluid order was transcribed in the medical record with an incorrect start date, setting the infusion to begin the following day instead of the same day, which created a delay in medical treatment. Attempts by surveyors to contact the nurse who transcribed the order were unsuccessful, and the regional nurse consultant could not explain why the order was not transcribed correctly.
Failure to Provide Medically-Related Social Services After Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services to address psychosocial well-being, behavioral needs, and follow-up after resident-to-resident incidents for two residents with dementia and mood disorders. One resident (R35) had vascular dementia with severe cognitive impairment, verbal behavioral symptoms toward others, and documented episodes of swearing, resisting care, and verbal and physical aggression toward a roommate. Another resident (R49) had major depressive disorder, generalized anxiety disorder, unspecified dementia with behavioral disturbance, and adjustment disorder, with documented episodes of yelling, verbal aggression, threatening behavior, and refusing care. The facility became aware of an allegation that R49 had been physically and verbally assaulted by R35, and later documentation described R35 becoming verbally aggressive and physically violent with a roommate, including an observation of attempting to hit the roommate through the curtain. Despite these incidents and the residents’ known behavioral and psychosocial conditions, the social services documentation was incomplete and lacked evidence of assessment and follow-up. For R35, social service progress notes since December consisted of only two entries related to family consent for continued medication, without details of the medication. An annual social service progress review for R35 was left incomplete in multiple sections, including cognitive/mental status comments, mood/behavior/emotional status, current mood and behavior status, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, and psychoactive medication review. There was no documented social services follow-up after the resident-to-resident incident in December or after the February incident where R35 became physically violent with the roommate. For R49, only one social service assessment was completed shortly after admission, and no quarterly assessment was available. That assessment was also incomplete, omitting documentation of behavior, medical and psychiatric history impact, admitting and historical behaviors or mood disorders, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, daily foods/drinks, and conflict-handling style, despite the resident being on a psychoactive medication and having a very low BIMS score. Clinical notes documented that R49’s family reported verbal aggression from the roommate and requested room changes, and psych services documented ongoing depression, anxiety, agitation, verbal aggression, and threatening behavior. However, there was no social services follow-up documented after the alleged abuse incident in December, the later roommate conflict, or the psych note describing significant psychosocial distress. Interviews with the Social Service Director revealed uncertainty about how psychosocial needs and behavioral monitoring were assessed and communicated, and the Administrator acknowledged expectations for follow-up that were not met, in contrast to the facility’s policy requiring initial and quarterly assessments, documentation of medically-related social service needs, and monitoring of residents’ mental and psychosocial functioning. The facility’s own policy on social services required the social worker or designee to complete initial and quarterly assessments for each resident, identify and document medically-related social service needs, and ensure that the care plan reflected ongoing psychosocial needs and how they were being addressed. The policy also specified services such as identifying individualized non-pharmacological approaches to meet mental and psychosocial needs and meeting the needs of residents coping with stressful events. In the cases of R35 and R49, the documented omissions in assessments, lack of detailed psychosocial and behavioral information, and absence of follow-up after resident-to-resident incidents and documented behavioral concerns demonstrate that these policy requirements were not followed, leading to the cited deficiency in providing medically-related social services to help each resident achieve the highest practicable quality of life.
Failure to Administer Seizure Medication Accurately and Timely
Penalty
Summary
The facility failed to ensure accurate and timely administration of a prescribed seizure medication for one resident. The resident had diagnoses including other seizures, neuromuscular bladder dysfunction, and multiple muscle contractures, and had a BIMS score indicating severe cognitive impairment. The resident had a physician’s order for Valproic Acid oral solution, 15 ml via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. Review of the MAR showed that on 9/15 the morning dose was documented as given by a nurse, and the evening dose was documented as given by another nurse. However, the facility’s Medication Admin Audit Report revealed that the 7:30 AM dose was actually administered and documented at 12:44 PM, well outside the one-hour before/after window described by the DON, and there was no record on the audit report that the 9:00 PM dose was administered at all. A complaint to the State Agency alleged that on that date the nurse falsified having given the resident their needed seizure medication, resulting in the resident sustaining two seizures during the night, and further alleged that this nurse often provided medications late or not at all. Nursing notes from the early morning of the following day documented that the resident experienced an active seizure at 4:23 AM and a second seizure at 4:23 AM lasting until 4:25 AM, with the resident positioned on the left side and suction available and the physician contacted. During interview, the DON confirmed that the Valproic Acid dose scheduled for 7:30 AM but administered at 12:44 PM was significantly delayed and that, after reviewing the audit, the 9:00 PM dose had not been administered. The facility’s Medication Errors policy stated that medications are to be administered according to physician orders and that time of administration and medication omission are factors indicating errors in medication administration.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure that the appropriate Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for three residents reviewed for beneficiary notification. The survey found that the residents and/or their representatives were not informed of potential private pay charges for continued services at the facility and were unable to file an appeal. The review included R10, R127, and R164, all identified from the facility’s list of residents who had Medicare A benefits within the past six months and were either discharged home or remained in the facility. Record review showed only SNF Beneficiary Notification Review worksheets for the three residents, with no additional documentation as instructed to show issuance of NOMNC and/or SNFABN forms. For R127, the worksheet stated Medicare A benefits began on 9/1/25 and ended on 11/19/25, and no SNFABN or NOMNC was issued because benefit days were exhausted. For R10, the worksheet stated Medicare A benefits began on 12/29/25 and ended on 2/16/25, with no SNFABN or NOMNC issued because benefit days were exhausted; R10 was also listed as being cut from Medicare A benefits on 10/8/25 and remaining in the facility, with no other documentation for that benefit period. For R164, the worksheet stated Medicare A benefits began on 7/15/25 and ended on 9/5/25, and a NOMNC was reportedly issued, but the NOMNC was not provided for review. When a NOMNC for R10 was later provided, it documented Medicare A benefits ending on 10/7/26 and included a note that the patient refused to sign and a copy was left at bedside, but there was no documentation that an SNFABN was provided for the resident’s continued stay in the facility. The facility also reported there were no SNFABN notices for residents who remained in the facility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to submit a notification of transfer to the State Long Term Care Ombudsman’s office for one resident who was transferred to the hospital. The resident’s record showed an initial admission to the facility, a transfer to the hospital, and diagnoses including congestive heart failure and chronic obstructive pulmonary disease. A progress note documented that the resident was observed to be extremely lethargic and confused, with blood pressure 118/62, heart rate 78, respiratory rate 14, blood sugar 183, and oxygen saturation of 89% on oxygen via nasal cannula, after which the nurse practitioner ordered transfer to the local hospital by 911. During the survey, the Administrator stated that notifications of transfers/discharges had not been sent to the State Ombudsman’s office and that Social Services was responsible for them. The Administrator reported that none had been completed for 2025 and that they had started in 2026. Social Worker C also stated that notifications for the requested November and December 2025 time period had not been completed and that they had started sending notifications in 2026. No documentation showing that the transfer notice for the resident had been sent to the Ombudsman’s office was provided by the end of the survey.
PASARR Level II Evaluation Not Available or Incorporated Into Care Plan
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) Level II evaluation was completed and implemented within one resident’s plan of care. The resident was admitted from another nursing home with diagnoses including adjustment disorder with mixed disturbance of emotions and conduct, borderline personality disorder, bipolar disorder in partial remission, bipolar disorder current episode mixed severe with psychotic features, and mood disorder. The Minimum Data Set documented intact cognition and verbal behavioral symptoms directed toward others, and another MDS assessment marked the resident as not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. The resident’s prior facility had completed a Level I PASARR form that documented bipolar disorder, borderline personality disorder, adjustment disorder with mixed disturbance of emotions and conduct, and psychotropic medications including olanzapine, haloperidol, and divalproex. However, there was no documentation in the current clinical record showing that a Level II evaluation had been completed before admission or that it was otherwise available in the record. During interview, the Social Service Director stated the admissions department usually obtained the paperwork, that they sometimes reviewed it, and that for this resident they guessed it had been done by the previous facility. The Social Service Director also stated they were the only person with access to the computerized PASARR system at that time. Later the same day, the Social Service Director located the resident’s Level II PASARR evaluation and uploaded it into the electronic record. The evaluation documented bipolar I disorder, alcohol use disorder, cocaine dependence, and recommended nursing home mental health monitoring, individual therapy, psychiatric medication review, psychiatric follow-up, and psychiatric consultation, with re-evaluation in 364 days. The record contained no documentation that the resident had been followed by social work from NSO, and the recommendations from the Level II evaluation were not included in the resident’s care plans or social service assessments and/or progress notes.
Missed Cardiology Appointment Not Communicated to Guardian
Penalty
Summary
The facility failed to coordinate a cardiology appointment for a resident with a pacemaker and renal dialysis dependence and failed to communicate with the resident’s legal guardian about the missed appointment. The resident was scheduled for a pacemaker follow-up with cardiology, but the appointment was not completed. The medical record contained no documentation explaining why the resident missed the appointment, and the guardian reported driving to the appointment location only to find that the resident did not arrive. The guardian stated the facility did not notify them before they traveled to meet the resident. Facility staff gave conflicting accounts of what happened. The unit secretary first stated the appointment had been cancelled, then said that was actually the MRI appointment, and later stated transportation did not pick up the resident as scheduled. The unit manager stated transportation arrived but could not find paperwork for the appointment, then said the appointment was cancelled after a second transportation company came later. Both staff members stated they did not speak with the guardian about the missed cardiology appointment, and the administrator acknowledged the miscommunication among departments and the lack of communication with the family/legal guardian.
Failure to Secure Indwelling Catheter
Penalty
Summary
Failure to provide appropriate catheter care was identified for one resident with an indwelling catheter. The resident was observed sitting up in bed with the catheter bag touching the floor and the tubing extended and taut. When asked, the resident reported pain from the catheter tube pulling. The tubing was observed without any method of securement to prevent pulling on the genitals. On a later observation, the resident’s catheter tubing contained cloudy urine and the drainage bag was crumpled in the privacy bag, preventing urine from flowing freely into the bag. The nurse stated the resident did not have a catheter securement device and that one would need to be obtained to prevent pulling on the genitals. The resident’s record showed diagnoses including UTI and Bell’s Palsy, a BIMS score of 8 indicating moderately impaired cognition, and a physician order requiring the catheter securement device to be changed every night shift every 7 days and as needed. The TAR showed the last administration of the securement device was several days earlier.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure residents received a clear understanding of the binding arbitration agreement and their right to refuse it for 3 of 72 residents reviewed for binding arbitration. The facility policy stated that residents must be informed in a form and manner they understand, including in a language they understand, and that the resident or representative must acknowledge understanding of the agreement. The facility’s tracking document showed 72 residents had agreed to the ADR agreement during the last 12 months. During interviews, R60 and R103 both stated they did not recall signing the agreement and were not familiar with what binding arbitration meant; when the surveyor explained that the agreement would prevent disputes from being resolved by a judge, jury, or trial, both residents said they would not have agreed to it. R60 had diagnoses including acute respiratory failure and depressive disorder and a BIMS score of 15/15. R103 had diagnoses including congestive heart failure, type II diabetes, and bipolar disorder and also had a BIMS score of 15/15. R152 reported that the agreement had never been explained as preventing disputes from being heard by a judge, jury, or trial and only recalled being told disputes under $20,000 would be handled in the facility; the resident did not recall signing documents. R152’s ADR document showed the agreement started on 2/19/26 and was electronically signed on 2/23/25, with no actual signature and nothing indicating the terms were fully explained. The Admission Director stated residents were given a large packet of documents and that the facility asked whether they would arbitrate disputes in house or outside for disputes less than $50,000, but also stated they did not have a complete understanding of what binding meant.
Failure to Provide Consistent Supervision for High-Risk Resident
Penalty
Summary
A facility failed to develop and consistently implement an adequate safety plan and provide sufficient supervision for a resident with a significant history of falls and severe cognitive impairment. The resident was admitted with multiple serious injuries from a prior fall, including intracerebral and subdural hemorrhages, spinal and rib fractures, and a right orbital fracture. Upon admission, the resident was noted to be restless, impulsive, and required staff assistance for all activities of daily living, with a care plan that included a one-on-one sitter due to high fall risk. Despite these interventions being documented, the facility did not consistently provide the required one-on-one supervision. Throughout the resident's stay, there were at least ten documented falls, several resulting in injuries such as hematomas, lacerations, and bruising, and requiring emergency department evaluation. Progress notes and interviews revealed that the resident was frequently agitated, difficult to redirect, and continued to attempt to stand or move unassisted. Staff and medical providers repeatedly documented the resident's need for close supervision, yet the one-on-one sitter was removed at some point prior to a significant fall, contrary to the established care plan. Staff interviews confirmed that the removal of the sitter was a management decision, and that the resident's supervision was insufficient during this period. The facility's administration acknowledged to the resident's legal guardian and to surveyors that they could no longer provide the one-on-one supervision as outlined in the care plan, and even requested the guardian to provide or pay for additional supervision. There was no documentation of a revised strategy or adequate alternative supervision plan, and the facility failed to ensure the care plan interventions were followed. The facility's own policy required individualized supervision based on assessed risk, but this was not adhered to, resulting in repeated falls and injuries for the resident.
Failure to Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and a recent clavicle fracture. The resident, who was dependent on staff for most aspects of care, was admitted, readmitted, and later discharged to the hospital following an incident where she claimed to have been pushed from her wheelchair by staff. The allegation was communicated to facility leadership via an email from the Transitional Care Liaison, which included a hospital case manager's note stating that the resident's son found her story inconsistent but agreed to a report being made to Adult Protective Services (APS). Despite being notified of the abuse allegation, the facility did not report the incident to the State Agency as required by both federal regulations and the facility's own policy, which mandates immediate reporting of all abuse allegations. During an interview, the Administrator acknowledged the decision not to report, stating that the team felt the incident did not occur. Facility documentation confirmed that the abuse allegation was not reported to the State Agency, constituting a failure to follow established procedures for reporting alleged violations.
Plan Of Correction
Element 1 - The facility identified resident #803 and they no longer reside at the facility. The administrator during this survey is no longer employed at the center effective 6/19/2025. Element II - The facility identified that all residents residing at the center could be affected by the deficient practice. The facility interviewed all patients who can be interviewed (BIMS>11), to ensure that any potential abuse allegations have been reported. There were no findings to report. Element III - The new facility administrator reviewed and understands the reporting requirements of the abuse policy. The facility educated the transitional care staff on proper abuse reporting methods to promote timely abuse reporting. Element IV - The facility administrator/designee will conduct 3 random interviews, weekly, times four weeks to ensure that all abuse allegations have been identified and reported. The results from those interviews will be submitted to the QAPI committee for review and recommendation. Element V - The administrator is responsible for achieving and maintaining compliance. The compliance date is 7/15/25.
Failure to Monitor and Address Severe Weight Loss in Resident with Malnutrition
Penalty
Summary
Facility staff failed to consistently assess, monitor, and review the nutritional needs of a resident with severe protein-calorie malnutrition, dysphagia, and recent surgical amputation. Upon admission, the resident had a documented history of inadequate energy intake, significant weight loss, and was identified as needing a regular diet with specific supplements and feeding assistance. Despite physician orders for weekly weights, the facility missed obtaining a required weight during the first week, and subsequent weights showed a rapid and significant decline in body weight. Throughout the resident's stay, food intake records indicated that the resident was consuming only 0% to 25% of meals, and multiple notes documented ongoing poor intake, difficulty swallowing, and a preference for fluids over solid foods. Although interventions such as supplements and a modified diet were ordered, the facility did not consistently implement or adjust these interventions in response to the resident's continued weight loss and declining intake. The care plan noted the need for feeding assistance and monitoring for signs of dysphagia, but documentation showed that these needs were not adequately addressed or modified as the resident's condition worsened. The facility's Registered Dietician did not identify or address the resident's significant weight loss until after the resident was transferred to the hospital for extreme weakness, lethargy, and refusal of food and fluids. Additionally, a dietary evaluation following the weight loss was incomplete and lacked documentation of interventions to prevent further decline. The facility's own policy required ongoing evaluation and modification of interventions for significant weight loss, but this was not followed, resulting in a severe weight loss of over 15 pounds within four weeks of admission.
Plan Of Correction
Element I- Resident #305 was identified and no longer resides at the center. All residents who reside at the center have the potential to be affected by the deficient practice. Element II- The facility completed an initial audit that consisted of pulling a PCC report for all residents who triggered for significant weight loss in the past 90 days. The facility reviewed the residents on report to ensure adequate interventions are in place to further weight loss. Element III- During morning clinical meetings, the facility IDT will review the EMR clinical dashboard for any resident who triggers for less than 50% of meal consumption and/or significant weight loss. The IDT will immediately assess the nutritional needs of those residents to ensure adequate interventions are consistently implemented and/or modified to prevent further weight loss. The facility will conduct weekly risk management meetings to complete follow-up on all residents who are identified as having weight loss and/or poor appetite. The facility will educate the RD/Designee, and members of the IDT which includes the DON, MDS, Unit Managers, and the Certified Dietary Manager on the Nutrition Monitoring and Management policy to promptly identify risk and address any concerns regarding weight loss or poor appetite. Element IV- The Registered Dietician/Designee will audit the medical records of 5 residents with triggered weight loss, four times over four weeks, then monthly for three months to ensure the facility is assessing, monitoring, and reviewing nutritional needs and intervention to prevent further weight loss of its residents. The audit results will be given to the administrator who will provide them to the QAPI committee for review and recommendations. Element V- The Administrator is responsible for achieving and maintaining compliance, the compliance date is 6/2/2025.
Failure to Conduct Thorough Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident. The resident was admitted to the facility, later went to the emergency room, and upon return, a review of their clinical record showed a progress note indicating the resident woke up confused and believed there was a man in their room. The facility's investigation file revealed that the only interviews conducted were with the resident's responsible party and two male staff members from the unit. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time of the allegation, the nurse who documented the resident's report, or any other residents. The Administrator/Abuse Coordinator confirmed that no additional staff or residents were interviewed and was unaware of the earlier report made by the resident about a man in their room. The facility's policy required a careful and deliberate investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. The investigation did not meet these requirements, as key staff and potential witnesses were not interviewed, and relevant information was not fully gathered.
Plan Of Correction
Element I: Resident #304 continues to reside in the facility and states that she feels safe. She was physically assessed by the charge nurse and provider. Resident #304 is followed by the facility social worker with no effect to mood or routine noted. The allegation of abuse was investigated and not verified. All residents have the potential to be affected by this citation. Element II: An initial “care concern” audit was completed to ensure that there were not any existing or new allegations of abuse. There was nothing remarkable to report. Element III: The Senior Administrator educated the facility administrator on the facility policy titled, “Nursing Administration...Subject: Abuse and Neglect.” The Senior Administrator also provided education on the contents of a proper investigation, including, but not limited to, reviewing PCC documentation. The facility educated its staff on abuse reporting. Element IV: The Senior Administrator will perform weekly audits on any investigative files should the need arise, to ensure that necessary contents are provided. The findings from those audits will be reviewed by the administrator and submitted to the QAPI committee for review and recommendation. Element V: The Administrator is responsible for achieving and maintaining compliance with
Failure to Timely Assess, Document, and Investigate Resident Fall
Penalty
Summary
A resident with hemiplegia, hemiparesis, and severely impaired cognition required partial to moderate assistance for shower transfers. During a shower, a CNA attempted to transfer the resident alone, despite the resident indicating she needed help. The resident subsequently fell to the floor on her knees and toes. The incident was not documented by the day shift staff at the time of the fall, and there was no immediate assessment or documentation of the event. The fall was only reported later during the midnight shift when the resident self-reported the incident and complained of pain in both lower extremities. An LPN documented the resident's account and provided pain medication, and a STAT x-ray was ordered. However, there was no documentation of a timely assessment or notification of management, the physician, or the resident's responsible party at the time of the fall, as required by facility policy. Further review revealed that the incident report was completed after the fact, and there was no documented investigation to determine the root cause of the fall. The post-fall assessment was initiated but left incomplete and not locked. The DON confirmed that there was no additional documented investigation and could not recall which staff were involved in the transfer or in assisting the resident after the fall. Facility policy required immediate assessment, documentation, and investigation, none of which were completed in a timely manner for this incident.
Plan Of Correction
Resident # 303 is currently not in the facility (unrelated to this citation). Resident 303's root cause for the incident was identified post-incident. The resident was assessed with orders for x-rays of her knee, ankle, hips, and back related to pain. No abnormal findings were identified. The resident's care plan was updated to have 2-person assistance with transfers. CNA no longer employed at the facility. Nurse Tyonna Hayes-King was provided 1:1 education on the Fall Management policy, with emphasis on what is considered an incident, timely assessment of a resident post-fall with investigation to determine root cause analysis, and reporting/documentation of all incident/accidents to the Director of Nursing. All residents have the potential to be affected by the deficient practice. An audit was conducted of all resident incident/accidents from the past 90 days to ensure all residents with incident/accidents were assessed, investigation completed to determine root cause analysis, and documentation, and care plans updated in the resident medical record. The DON/designee spoke with all residents who were able to be interviewed for any incident/accident/falls that have not been reported. None were identified. The DON/designee will review all incident/accidents from the previous day/weekend during daily clinical meetings to ensure residents with incident/accidents have been assessed timely after a fall, and investigation is completed to determine root cause analysis. The DON/unit managers will provide focused oversight during daily rounds on the units and provide educational opportunities and reminders to staff who provide care to residents to ensure any incidents that occur while providing care are immediately reported for investigation. This will include random interviews with residents while rounding daily. By 5/21/2025, licensed nurses and certified nursing assistants will be educated on the Best Practice Fall Management policy with emphasis on what is considered a fall (examples of residents being lowered to the floor), head-to-toe assessments of residents in a timely manner, investigations to determine root cause analysis, and reporting of incident/accidents. The DON/designee will audit all risk management reports weekly for 4 weeks and then monthly for 3 months or until substantial compliance has been maintained to ensure that nurses are following the policy for risk management and falls, with emphasis on assessing residents in a timely manner and investigation to determine root cause analysis for falls. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
Failure to Obtain STAT Laboratory Services as Ordered
Penalty
Summary
The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.
Plan Of Correction
Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
A resident was admitted to the facility and later reported to have been sexually abused. The clinical record showed that the resident expressed confusion and reported to a nurse that she believed a man had been in her room. Subsequently, while at the hospital, the resident alleged to police that she had been raped by a male caregiver, but later denied the allegation. The facility's investigation file indicated that only the resident's responsible party and two male staff members from the unit were interviewed. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time, the nurse who documented the initial report, or other residents. The facility's abuse and neglect policy required a thorough investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. However, the investigation did not include interviews with all potentially relevant staff or residents, and the Abuse Coordinator was unaware of the initial report made by the resident to the nurse. The documentation and investigation process did not meet the facility's stated policy requirements for a careful and deliberate investigation.
Inadequate Infection Control for MRSA Case
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for all 82 residents, as evidenced by the mishandling of a MRSA infection case. A resident was informed by their dermatologist that a culture from a cyst on their head tested positive for MRSA, a contagious infection. Despite being placed on contact precautions and started on an antibiotic, the facility did not adequately clean the resident's room or ensure staff wore appropriate protective equipment. The resident reported that staff were not wearing gowns during care and that the facility did not notify external providers about the infection when the resident was transported for physical therapy and other appointments. The facility's infection control surveillance program was found lacking, with no infection control data, including surveillance, line listing, mapping, and analysis reports, available for November 2024, December 2024, and January 2025. The Director of Nursing was unaware of the MRSA case and any potential trends in the facility, and the Infection Control Preventionist was absent during the survey. The Administrator confirmed that the last Quality Assurance meeting did not review November's infection control report, and no additional data was provided before the survey concluded. The facility's policy on infection prevention and control mandates ongoing monitoring and documentation of infections, which was not adhered to in this case.
Failure to Maintain Hot Water Supply Due to Lack of Boiler Inspections
Penalty
Summary
The facility failed to maintain proper functioning of the hot water supply, affecting all 82 residents. The deficiency was identified when it was reported that the facility had no hot water from January 11 to January 16, 2025, due to both hot water boilers failing. During an interview, the Maintenance Director (MD C) confirmed the lack of hot water and revealed that the boilers had not undergone the required CSD-1 inspection in 2024. The inspection was delayed because the boilers needed maintenance and cleaning, and although a quote was sent to the corporate office, no further action was taken. The facility's preventive maintenance policy requires regular inspections and maintenance of equipment, including boilers, to ensure compliance with applicable codes. However, the facility did not have documentation of the annual CSD-1 inspection for 2024 or 2023, only a receipt of service. The CSD-1 code mandates that controls and safety devices of boilers be tested annually, and the facility failed to comply with this requirement, leading to the prolonged hot water outage.
Failure to Document and Follow Up on MRSA Diagnosis
Penalty
Summary
The facility failed to ensure that the physician evaluated the total program of care for a resident, specifically regarding a newly developed skin impairment. The resident, who had a history of type 2 diabetes mellitus and lymphedema, reported a pus-filled blister on his scalp to the attending physician. The physician initially dismissed it as a common condition for diabetics and prescribed an antibiotic, Keflex, without documenting the condition properly in the medical records. The resident, concerned about the unusual nature of the blister, sought a second opinion from a dermatologist, who diagnosed the condition as MRSA, a contagious infection. Despite the dermatologist's diagnosis and the resident's notification to the facility, the attending physician failed to document the MRSA diagnosis or the treatment plan in the medical records. Progress notes from the physician repeatedly indicated no new concerns and did not mention the skin impairment or the MRSA diagnosis. The resident's medical records showed orders for antibiotics and contact precautions for MRSA, but these were not reflected in the physician's documentation. Interviews with the physician and the Director of Nursing revealed a lack of thorough documentation and follow-up on the resident's condition. The physician admitted to a documentation error and could not provide evidence of proper assessment or follow-up for the skin impairment. The Director of Nursing confirmed that the facility's expectations for physician evaluations were not met, as the documentation lacked accuracy and thoroughness regarding the resident's change in condition.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, specifically in the areas of regular bathing and transfers. The resident, identified as R803, was observed waiting for assistance to transfer from their bed to a wheelchair for approximately two hours. The resident reported that the CNA was aware of their need but did not return to assist after helping another resident with eating. The resident also indicated that they rarely received showers due to the staff's reluctance to help them, despite needing maximal assistance for such tasks. The medical record review revealed that R803 had only received two showers since their admission, with no documented refusals of showers, except for two instances where the resident chose not to have their hair washed. The Director of Nursing confirmed that residents should be offered showers at least twice a week and that staff should document when a shower is provided or refused. However, there was no additional documentation to support that R803 had been offered or provided scheduled bathing as required.
Failure to Monitor and Document Skin Impairment and MRSA Diagnosis
Penalty
Summary
The facility failed to properly identify, monitor, and assess a skin impairment for a resident, R802, who had consulted with a physician about bumps on his scalp. Despite being informed by the resident that the bumps were spreading and having a dermatologist appointment, the facility did not document any skin impairments on the resident's head or scalp. The resident was later diagnosed with MRSA by the dermatologist, but this information was not adequately followed up by the facility. Interviews and record reviews revealed that the resident had informed the facility of his dermatologist appointment and provided the paperwork to a registered nurse. However, there was no documentation of the skin impairment in the resident's clinical record, and the facility's staff, including the attending physician and the Director of Nursing, were unaware of the MRSA diagnosis. The facility's protocols for documenting and following up on new skin impairments were not adhered to, as evidenced by the lack of documentation and assessment of the resident's condition. The facility's failure to document and follow up on the resident's skin condition and MRSA diagnosis was further compounded by the lack of communication and coordination among the care team. The attending physician and registered nurse provided conflicting accounts of the resident's treatment, and the Director of Nursing was unaware of the MRSA diagnosis despite existing physician orders for treatment and contact precautions. This lack of documentation and follow-up highlights a significant deficiency in the facility's care and monitoring processes.
Failure to Return Residents' Clothing Timely
Penalty
Summary
The facility failed to ensure that personal clothing items sent to the laundry were returned to residents in a timely manner. During a Resident Council meeting, several cognitively intact residents reported missing clothing items, including green shirts, pants, and other personal garments. Despite reporting these issues, the residents did not receive their clothing back nor compensation to replace them. Past Resident Council Minutes also documented similar grievances, indicating a pattern of missing clothing items and delayed returns. Interviews with facility staff revealed awareness of the issue. The Activity Director acknowledged the complaints and stated that grievance forms were completed and forwarded to the Administrator. Laundry staff, employed by an outside company, noted that the problem often arose from facility staff failing to label clothing bags with residents' names and room numbers, making it difficult to return items correctly. The Housekeeping Director confirmed the issue, showing the surveyor bins of unlabeled laundry, which complicated the return process. The Administrator recognized the problem and mentioned that some residents or their families were reluctant to label clothing, although alternative solutions were acknowledged.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a medication administration session with an LPN. Loose, unidentifiable medications were found in the medication cart labeled as Cart C Hall. Specifically, the cart contained several loose pills, including a round white pill with no identifier, two round white pills stamped 337, a half peach-colored pill, a round pink pill stamped R50, a quarter white pill, a round pink pill stamped IG/207, and a half white round pill. The LPN acknowledged that these medications were not properly stored and should not be loose without patient identifiers. Additionally, the medication room identified as Traverse had two stacked refrigerators, with the top refrigerator storing insulin lacking a thermometer and temperature logs. The LPN confirmed that the refrigerator's temperature should be monitored and recorded, but was unsure why the thermometer was missing. The Director of Nursing was informed of these observations and acknowledged the need for temperature monitoring in the refrigerator and proper storage of medications in the cart. The facility's policy on medication access and storage, dated July 2018, requires medications needing refrigeration to be kept in a refrigerator with a thermometer for temperature monitoring.
Contaminated Linen Storage in Laundry Room
Penalty
Summary
The facility failed to maintain clean storage of linens and resident clothing in the laundry room, leading to contamination with dust and dryer lint. During a tour of the laundry room, two linen carts containing clean folded linens, comforters, and clothing were observed to be covered with large amounts of thick white fuzzy debris. The right cart's green protective sheet panel was lifted to reveal a cardboard box and wheelchair adaptive equipment also covered with the debris. The left cart had folded cardboard boxes used as a top shelf, which were covered with dusty material, and a half-consumed water bottle was found on it. Housekeeping Manager B and Assistant Housekeeping Manager C acknowledged the presence of clean laundry on the carts and confirmed the contamination with dust and dirt, deeming the conditions unhygienic. The facility was unable to provide a clean laundry storage policy by the end of the survey.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident with Chronic Obstructive Pulmonary Disease and Adjustment Disorder, who was independent in most activities of daily living and had intact cognition. The resident alleged that a Certified Nursing Assistant (CNA) verbally threatened him with physical harm during an altercation at the nurse's station. The resident reported that the CNA told him she would 'beat his ass' after he refused to leave the nurse's station and began swearing at her. Witnesses, including another CNA and a receptionist, confirmed hearing the CNA use threatening and abusive language towards the resident. The facility's investigation included interviews with the involved parties and a review of the resident's medical record and the CNA's personnel file. The CNA admitted to using inappropriate language but denied making any threats. However, both the receptionist and another CNA corroborated the resident's account, stating they heard the CNA use threatening language. The facility determined that the CNA violated multiple work rules, including using profane language and failing to show respect to the resident. The Director of Nursing acknowledged that the CNA's behavior was unprofessional and confirmed that the CNA was terminated for multiple violations of work rules. The facility also conducted a house-wide re-education of staff on abuse and neglect policies to prevent future incidents. The facility's policy on resident rights and abuse was reviewed, emphasizing the importance of providing care in an environment free from any type of abuse, including verbal abuse.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,193 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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Bloomfield Health And Rehabilitation Center | 1 mi | ★★★★★ | 2 | 0 |
| Notting Hill Of West Bloomfield | 1.1 mi | ★★★★★ | 23 | 0 |
| Marvin & Betty Danto Health Care Center | 1.5 mi | ★★★★★ | 6 | 0 |
| The Villa At Green Lake Estates | 4.2 mi | ★★★★★ | 4 | 1 |
| Fox Run Village | 4.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.