Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Ann Arbor during CMS and state inspections, most recent first.
Resident Council grievances about slow call light response times were not addressed or resolved. Residents reported repeated waits of more than 1 hour on night shift, including some waits of 2 hours for assistance back to bed, and said the issue had been raised at every council meeting for months without improvement. Meeting minutes did not reflect the concern, no grievance forms were found, and residents were unaware of the grievance process, while the NHA stated residents had not reported concerns despite nursing issues being listed on the grievance log.
A resident with chronic pain, anxiety, and other diagnoses reported repeated delays of more than two hours in receiving pain medication due to slow call light response times, mostly on nights, and said the issue was not fully addressed when he raised it with the unit manager. In a confidential Resident Council meeting, residents said call light delays had been ongoing for months, yet none knew where to find or how to complete grievance forms or how the grievance process worked. Surveyors could not find accessible grievance forms, and both the UM and NHA reported the forms were not readily available at nurse stations.
Failure to Maintain Clean and Safe Physical Plant: A facility environmental review found damaged drywall behind a bed headboard, a non-functional overhead light bulb, heavily soiled and stained wall surfaces and wall/floor junctures near a restroom entrance, and laundry area light lens covers covered with dust, dirt, and dead insect carcasses. A shower grab bar in the central bath was also loose-to-mount, while the maintenance work order review showed no specific entries for the observed concerns despite existing PM and environmental inspection policies.
A resident with polyosteoarthritis and cognitive decline developed an unexplained humerus fracture after a shower, with x-ray confirming an acute supracondylar fracture. The facility’s abuse investigation was incomplete because it relied on a phone call and chart review, included only one interview, and did not document interviews with the resident, the LPN, other staff, or other residents.
PASARR Screening Not Completed or Referred for Level II Evaluation: A resident admitted with MH diagnoses and moderate cognitive impairment had no PASARR documentation in the chart. Staff could not locate the Level I or Level II forms, and the OBRA website did not show a Level II referral. The later-obtained Level I screening showed yes responses for mental illness, MH treatment, and psychotropic medication use, but the physician-signed exemption form had no criteria selected and the resident was not referred for a Level II OBRA eval.
The facility failed to provide medications timely and as prescribed for two residents and failed to ensure a physician order was in place for another resident. One resident reported dry, burning eyes and progress notes referenced artificial tears, but no active or discontinued order was found. Another resident’s BP meds were repeatedly given late beyond the facility’s grace period. A third resident’s weekly Trulicity was inconsistently documented, sometimes unavailable, sometimes not charted, and at least one dose was recorded as given despite the resident reporting it was not received.
Failure to provide timely pain management for a resident with chronic pain, radiculopathy, heart disease, HTN, and anxiety. The resident reported long delays in call light response for PRN pain meds, often more than 2 hours at night, and said he received pain meds less often than usual, which left him unable to sleep and unable to attend therapy due to uncontrolled pain. Record review showed PRN pain meds were often given with scheduled med pass and pain assessments were sometimes completed up to 12 hours late.
Incomplete and inaccurate resident medical records were identified for three residents. One resident’s chart lacked PASARR documentation despite psychiatric diagnoses and moderate cognitive impairment, another resident’s MAR showed Trulicity as given even though the LPN said it was not administered because it was out of stock, and a third resident’s dialysis communication forms were missing from the record, with many forms found outside the chart by the DON.
A resident receiving hospice services had conflicting code status documentation across the EMR, physician orders, hospice records, and care conference notes. The resident’s chart showed both Full Code and DNR entries, the care conference documented the resident as Full Code without hospice participation, and hospice records identified the resident as DNR. Interviews with SW, ADON, the DPOA, and hospice SW showed the facility and hospice were not aligned on the resident’s advance directives and code status.
Failure to follow infection control standards during eye drop administration for a resident with glaucoma. An LPN was observed giving eye drops to the resident's right eye without wearing gloves, despite the facility procedure requiring hand hygiene and clean gloves before administration. The DON stated staff were expected to wear gloves when administering eye drops.
Failure to Post Actual Daily Nursing Staffing Data: The facility posted a staffing sheet that listed scheduled staffing totals by shift rather than the actual hours worked. The Staffing Coordinator stated she was responsible for posting the document but had not been educated to post actual hours worked, and the DON confirmed the posted information did not include actual staffing hours as required.
Missing Controlled Medications and Inaccurate Controlled Substance Records A resident’s oxycodone blister pack went missing from the med cart, and the controlled substance count sheets had unclear and incomplete entries at shift change. Surveyors also found multiple controlled meds for several residents were short on two carts, with staff saying the doses were given and documented on the MAR but not on the controlled substance forms. The DON stated controlled meds should be signed out right away when removed from the cart.
A resident who required a two-person assist for bed mobility was left in the care of a CNA who, unable to find assistance, provided care alone against the care plan. The resident was later found on the floor with multiple injuries, including bilateral femur fractures, and was not transferred to the hospital for several hours. The resident died from blunt force trauma related to the fall.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 134 residents. Observations included soiled ventilation grills, dirty light covers, and a lack of date marking on milk. Additional issues were found in food service pantries, such as damaged equipment and mineralized ice machine spouts. These deficiencies indicate non-compliance with the 2022 FDA Model Food Code and inadequate implementation of the facility's sanitation and maintenance policies.
The facility failed to maintain cleanliness and repair issues, affecting 138 residents. Observations revealed worn floor mats, damaged flooring, stained carpets, and soiled air conditioning filters. Common areas had damaged furniture, missing fixtures, and soiled surfaces. Resident rooms had non-functional lights, damaged surfaces, and soiled bedding. The facility's work order system lacked entries for these issues, indicating ineffective maintenance tracking.
A resident with multiple sclerosis and cognitive intactness expressed frustration over the facility's failure to honor his choices regarding his morning routine and outdoor access. Despite a physician's order allowing him to leave the facility, he was consistently denied the opportunity to go outside independently in his motorized wheelchair. The facility's care instructions prohibited him from exiting, contributing to his feelings of depression and frustration.
A resident with cognitive and physical impairments did not receive necessary oral care assistance at an LTC facility. Despite an order for oral care supplies to be prepared, the resident reported not having their teeth brushed since admission and lacked the supplies to do so independently. Observations confirmed the absence of toothpaste and an unused toothbrush. The issue was only addressed after state agency involvement.
A resident in an LTC facility experienced loss of personal clothing, affecting their psychological wellbeing. Despite being cognitively intact and labeling clothes to prevent loss, the resident was observed in a hospital gown due to missing items. The resident reported the issue to the DON, but no formal grievance was filed, as the resident was unaware of the process. The facility's grievance logs lacked documentation of the resident's complaints, indicating a communication gap.
A resident with cognitive impairment and behavioral disturbances was documented by an LPN as verbally abusing and threatening another resident. The LPN did not report the incident, and the Nursing Home Administrator was unaware of it, resulting in a failure to follow required abuse reporting procedures.
A resident with cognitive impairment and behavioral disturbances was documented by an LPN as verbally abusing and threatening another resident. The LPN did not report the incident, and the NHA was unaware of the allegation, resulting in no investigation being conducted.
Two residents with cognitive and behavioral impairments did not have comprehensive care plans addressing repeated incidents of wandering and entering other residents' rooms. Despite documented behaviors and staff observations, care plans lacked interventions to minimize these actions, and the DON confirmed the absence of appropriate planning.
Two residents with physical limitations and intact cognition did not receive scheduled showers as outlined in their care plans. Instead, staff offered bed baths due to inadequate staffing, and when the residents declined the bed bath, it was documented as a refusal of a shower. Staff interviews confirmed that insufficient staffing and high resident acuity prevented completion of required care tasks, including showers, and nursing leadership stated that residents should receive showers if requested.
Several residents requiring assistance with mobility and personal care experienced long delays in call light responses and were not provided scheduled showers, as staff frequently reported being too busy and offered bed baths instead. Direct care staff and a staffing coordinator confirmed that staffing assignments were based on census rather than resident acuity, leading to incomplete care tasks and extended wait times for residents. Staff also faced challenges covering multiple units, further delaying care and leaving essential needs unmet.
A facility failed to include necessary communication and coordination with an endocrinologist in a resident's care plan, despite the resident having Type II Diabetes and specific instructions in the EMR for managing blood glucose levels. The care plan omission was acknowledged by the DON as an area for improvement.
A facility failed to follow a physician's order to coordinate diabetes care with an endocrinology clinic for a resident with multiple malignancies, resulting in unmanaged high blood glucose levels. Despite an order to contact endocrinology for frequent high glucose levels, there was no documentation of such communication over several days. Interviews revealed a lack of clarity and coordination in communication with endocrinology, which was acknowledged by the DON as a concern.
A resident with a history of infection and prosthetic heart valve was prescribed Vancomycin for C-Diff, to be taken every six hours. The resident missed three doses due to a perceived lack of stock, leading to dissatisfaction and leaving the facility for medical care. Interviews revealed a misunderstanding about the availability of backup medication in the PYXIS system, which was later found to have the necessary medication in stock.
Resident Council Grievances About Call Light Delays Were Not Addressed
Penalty
Summary
The facility failed to address and resolve grievances raised in Resident Council meetings regarding slow staff response to call lights. During a confidential Resident Council meeting, 10 of 10 residents who participated reported ongoing problems with call light response times, including waits of greater than 1 hour on night shift and, in some cases, waits of at least 2 hours to be assisted back to bed. Residents stated the issue had been discussed at every Resident Council meeting for months without improvement, and several residents reported that the concern had also been brought to the DON multiple times. The residents, including the Resident Council President, verified that long call light response times had been discussed at prior meetings and with the DON, but no improvements had occurred and the wait times remained greater than 1 hour about three times weekly on night shift. Review of six months of Resident Council meeting minutes showed no mention of call light response times, and no concern forms were found. Ten of ten confidential residents were not aware of where to locate or how to complete a grievance form or how the process worked. The NHA reported attending Resident Council meetings and stated residents were routinely asked about call light response times and had not reported concerns, while also acknowledging several nursing concerns on the grievance log related to call light response times.
Grievance Forms Not Accessible and Resident Concerns Not Promptly Addressed
Penalty
Summary
The facility failed to notify residents of where to find grievance forms and how to file a grievance. Resident #169 was a cognitively intact male with diagnoses including hypertension, heart disease, radiculopathy, chronic pain, and anxiety. During an interview, he reported ongoing concerns with call light response times greater than two hours when requesting pain medication, mostly on nights, and said he had been unable to sleep and unable to attend therapy because of uncontrolled pain. He stated he reported the issue to the unit manager, who told him the facility planned to change medication timing, but his concern about the long call light response times was not addressed. During a confidential Resident Council meeting, 10 of 10 residents who participated said they were not aware of where to locate or how to complete a grievance form or how the grievance process worked. Residents reported slow call light response times had been discussed at every Resident Council meeting for months without improvement, including waits of more than one hour on night shift and up to two hours for assistance back to bed. Surveyors were unable to locate easily accessible grievance or concern forms during a facility tour. The Unit Manager and the Nursing Home Administrator both reported grievance forms were supposed to be at nurse stations, but they could not locate them there and stated the forms were not available to residents or families without asking. The DON reported becoming aware of Resident #169's medication concerns only when questioned by the Unit Manager, and the NHA later reported not having seen the resident's concern form dated 7/7/26.
Failure to Maintain Clean and Safe Physical Plant
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant for 143 residents. During environmental assessments, a resident room had a 503-W drywall surface directly behind the bed headboard that was scraped, scored, and fragmented from repeated bed movement, and the overhead light assembly lower bulb was non-functional. Another resident room had a heavily soiled and stained drywall corner and plastic protective edge guard adjacent to the restroom entrance, with three pieces of transparent tape adhered to the edge guard, and the wall/floor juncture surfaces beside the restroom entrance were heavily soiled with accumulated and encrusted dust, dirt, and grime and were extremely dark in color. During an environmental tour of the Laundry Service area, all overhead clear plastic light lens covers in both the clean laundry room and the laundry room were observed soiled with accumulated and encrusted dust, dirt, and dead insect carcasses. In the Meadows central bath, 1 of 3 shower stall grab bars was observed loose-to-mount. The Director of Housekeeping and Laundry stated she would contact maintenance for cleaning or repairs, and record review showed the facility had a Preventative Maintenance Program and an Environmental Services Inspection policy requiring a safe, functional, sanitary, and comfortable environment, but the manual maintenance work orders for the last 90 days contained no specific entries related to the observed concerns.
Incomplete investigation of unexplained fracture
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident who was admitted with polyosteoarthritis and age-related cognitive decline and who was not in the facility at the time of survey because she had been transferred to the hospital. After a CNA gave the resident a shower, the resident began holding her left elbow and crying out in pain, and a stat x-ray showed an acute transverse supracondylar fracture of the humerus with partial comminution at the medial epicondyle and mild impaction of fracture fragments. The resident was transferred to the hospital and later returned to the facility. The facility’s incident report for the fracture included only one interview and did not include interviews with the resident, other residents, the resident’s nurse, or staff from the current or previous shifts. The NHA, who stated she was also the Abuse Coordinator and conducted the investigation, reported she relied on a phone call from an LPN and the nurse’s note, and did not obtain a written statement from the LPN. She also stated she attempted to interview the resident through a translator, but the translator said the resident was too confused to be interviewed, and this attempt was not documented. The NHA further stated she did not interview additional staff or residents because she reviewed the record, found no concerns, and believed the resident’s family would have reported any problem.
PASARR Screening Not Completed or Referred for Level II Evaluation
Penalty
Summary
The facility failed to ensure a Level I pre-admission screening was completed and referred for a Level II evaluation and determination for one resident. The resident was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood and post-traumatic stress disorder (PTSD). The Minimum Data Set with an assessment reference date of 6/12/26 showed the resident scored 11 out of 15 on the BIMS, indicating moderate cognitive impairment. Review of the medical record found no Level I or Level II PASARR documentation in the chart. During interviews, the Social Worker reported they could not locate the resident’s Level I or Level II PASARR and said it was possible admissions staff had a copy. The OBRA website did not show that the resident had been referred for a Level II evaluation. The Social Work Director stated the resident should have had a Level I PASARR in the medical record. The Nursing Home Administrator later reported the facility had to contact the VA to obtain the PASARR documents because they were not available in the facility. The documents received from the VA showed the Level I screening was completed and marked yes for current mental illness, treatment for mental illness, and psychotropic medication use within the last 14 days, which required a comprehensive Level II OBRA evaluation unless an exemption applied. The physician-signed certification form did not have any exemption criteria selected, and the resident was not referred for a Level II evaluation.
Medication Administration and Order Documentation Failures
Penalty
Summary
The facility failed to provide medications timely and as prescribed for two residents and failed to ensure a physician order was in place for one resident. One resident with optic atrophy, muscle weakness, major depressive disorder, anxiety disorder, and intact cognition reported that his eyes burned and were dry and irritated, and that a provider had told him eye drops would be ordered to help. Progress notes documented dry eye syndrome and that artificial tears should be continued or used, but a review of physician orders showed no active or discontinued order for artificial tears. Another resident with schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and intact cognition reported that his morning blood pressure medications were frequently given late. The physician orders directed amlodipine 5 mg and metoprolol succinate ER to be given at 9:00 AM, but the medication administration audit showed amlodipine was given late seven times in the prior 30 days and metoprolol was given late three times, with several administrations occurring after the facility’s one-hour grace period. A third resident with type 2 diabetes mellitus and intact cognition was prescribed weekly Trulicity injections. The MAR and progress notes showed multiple instances where the dose was refused, not documented as given, marked as unavailable, or recorded with no explanation, including times when the medication was not available, when the resident was away from the facility, and when documentation did not match the resident’s report. Pharmacy packing slips showed deliveries on several dates, but there was no delivery on one date when the medication was documented as unavailable, and on another date the MAR showed the dose as administered even though the resident reported it was not received.
Failure to Provide Timely Pain Medication
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not ensured for a cognitively intact male resident with diagnoses including hypertension, heart disease, radiculopathy, chronic pain, and anxiety. The resident reported ongoing concerns that call light response times for pain medication requests were often greater than two hours, mostly at night, and stated that on 7/6/26 he received pain medication four times even though he usually received it five to six times daily to manage his pain. He also reported that he was unable to sleep the prior night and unable to attend therapy that morning because of uncontrolled pain, which he said was the reason he was in the facility for rehab. The resident stated that when staff answered the call light and he requested PRN pain medication, staff returned to tell him that the nurse said he would receive it with scheduled medication during medication pass. He reported this had happened before and that he became frustrated and complained to the unit manager. Record review showed the MAR from 7/1/26 through 7/7/26 reflected several PRN pain medications were administered with scheduled medication pass, and several pain assessments were completed up to 12 hours after they were ordered. The care plan identified the resident as at risk for pain and directed staff to administer pain medication as ordered and notify the physician if pain frequency or intensity worsened or if the analgesia regimen became ineffective. The unit manager completed a grievance form related to the resident's complaint and reported the physician was contacted and pain medications were changed to scheduled.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 3 of 27 residents reviewed. For one resident admitted with adjustment disorder with mixed anxiety and depressed mood, PTSD, and anxiety disorder, the record showed moderate cognitive impairment on the BIMS, but no Level I or Level II PASARR was found in the chart. The SW reported the PASARR could not be located, the SWD stated the resident should have had a Level I PASARR in the medical record, and the NHA later reported the facility had to call VA to obtain the PASARR documents because they were not available in the facility or in the resident’s record. For another resident with type 2 diabetes mellitus, weekly Trulicity was ordered and remained active, but the MAR documented the dose as administered on a day when the resident later reported it was not received because it was not in stock. The LPN stated she did not administer the dose and had to reorder it, while the ADON was not aware the dose had not been given. For a third resident with end stage renal disease receiving hemodialysis 3 times a week, the chart contained only 8 dialysis communication forms when there should have been roughly 85. Medical records staff described the process for completing and filing the forms, the LPN/UM reported having some of the dialysis sheets in her office for review and signature, and the DON later produced 43 additional dialysis communication forms that were not part of the medical record.
Hospice Code Status Not Coordinated With Advance Directives
Penalty
Summary
The facility failed to coordinate care with hospice to ensure the accuracy of advance directives for one resident receiving hospice services. The resident was admitted with diagnoses including malignant neoplasm of the pancreas, adjustment disorder with mixed anxiety and depressed mood, and PTSD, and the MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15. The resident’s electronic medical record contained conflicting code status information, including a main profile entry indicating full CPR, a scanned physician order showing DNR, and another electronic physician order showing Full Code. The social work note stated the resident was full code pending a valid DNR signed by the DPOA, while the physician H&P documented the patient as DNR. The care conference record showed no indication that hospice staff were invited or attended, and the conference documented the resident as full code. Hospice records, including the IDG comprehensive assessment and plan of care update and social work documents, identified the resident as DNR. The hospice binder at the nurse’s station contained a DNR order signed by the DPOA and one hospice staff witness, but a second witness and the physician had not signed it. In interviews, the SW stated the resident was full code and said the DPOA did not wish to change the code status to DNR, while the DPOA stated she understood the code status was going to be changed to DNR after the care conference and that she had not been asked to sign anything further. The ADON stated the resident was full code and was unaware that hospice paperwork indicated DNR, and the hospice SW stated hospice had requested to be included in care conferences but was not directly contacted to participate.
Failure to Follow Infection Control During Eye Drop Administration
Penalty
Summary
The facility failed to maintain infection control standards during eye drop administration for one resident with glaucoma. The resident was admitted with a diagnosis of glaucoma, and the physician's order dated 7/6/26 directed Cosopt ophthalmic solution 2-0.5% to be instilled as one drop in the right eye two times a day. On 07/08/2026 at 8:49 AM, an LPN was observed administering dorzolamide 2% eye drops to the resident's right eye without wearing gloves. The LPN pulled down the resident's right lower eyelid and placed one drop in the right eye. The facility's Medication-Eye Drop or Ointment Administration procedure dated 9/14/23 directed staff to perform hand hygiene and don clean gloves before administration, and the DON stated in interview that staff were expected to wear gloves while administering eye drops.
Failure to Post Actual Daily Nursing Staffing Data
Penalty
Summary
The facility failed to post the actual daily Nursing Staffing Data, resulting in the potential for all 143 residents and their families or visitors to be informed of the facility's staffing information. During observation on 07/09/2026 at 09:24 a.m., the posted document titled 8(SP)Resident Care & Complaint Intake Staff was seen in a glass case across from the Nursing Home Administrator's office. The document was dated 07/08/2026 and showed a resident census of 146, with staffing listed by shift and job classification, including totals and total hours for RN, LPN, CENA, MDS-RN, and other categories. During interview on 07/09/2026 at 10:08 a.m., the Staffing Coordinator stated she was responsible for posting the document each day and explained that the hours shown were scheduled hours to be worked, not actual hours worked for each shift. She stated she had not been educated to post the actual hours worked at the end of the shift. During interview on 07/09/2026 at 10:22 a.m., the DON confirmed that the posted document dated 07/08/2026 did not include actual hours worked for each shift and stated she did not know that federal statute 483.35(iii) required the facility to post information that included actual hours worked.
Missing Controlled Medications and Inaccurate Controlled Substance Records
Penalty
Summary
The facility failed to prevent a missing controlled substance medication for one resident and failed to maintain accurate controlled substance records for five other residents. One resident had diagnoses including low back pain, chronic pain, and systemic lupus erythematosus, and the January 2026 MAR showed an order for oxycodone 10 mg every six hours as needed for pain. A blister pack of that resident’s oxycodone was reported missing between the 7:00 AM and 7:00 PM nursing shift on 1/30/26, after the medication had been delivered to the facility on 1/28/26 and doses had been documented as administered through 1/30/26. The facility’s investigation and controlled substance shift inventory documentation showed unclear counts at shift change and incomplete entries for the controlled medication log. The outgoing and oncoming nurses signed for the total number of controlled medications at 7:00 AM, but the starting and ending counts were unclear. A later entry at 7:00 PM also had an incomplete date, unclear starting count, one medication documented as received from the pharmacy, and an ending count of 9 without the oncoming nurse’s signature. During the investigation, the DON reported that the oxycodone delivered for the resident was missing and that the count sheet for the medication could not be found. During a controlled substance count on two medication carts, surveyors found discrepancies between the documented stock and the actual medications present. For one cart, oxycodone, pregabalin, morphine sulfate, methadone, and oxycodone for five residents were each short by one or two units compared with the Controlled Drug Receipt/Record/Disposition Form, and staff stated the medications had been administered and signed out on the MAR but not on the controlled substance form. On the second cart, pregabalin for another resident was also short by one capsule, and the nurse reported it had been administered but not signed out on the controlled substance form. The DON stated nurses should sign controlled medications on the Controlled Drug Receipt/Record Disposition Form right away when the medication is removed from the medication cart.
Failure to Follow Care Plan Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with significant physical disabilities, morbid obesity, and moderate cognitive impairment was care planned to require a two-person assist for bed mobility and activities of daily living. The resident was totally dependent on staff for movement and unable to reposition or turn independently. On the night of the incident, a Certified Nurse Aide (CNA) was unable to locate another staff member to assist with the resident's care, despite waiting and searching for approximately 45 minutes. The CNA proceeded to provide bed mobility care alone, contrary to the resident's care plan, and subsequently found the resident on the floor after leaving and returning to the room. Upon assessment by a nurse, the resident was found with a skin tear to the left elbow, hematomas to the left knee and left side of the forehead, and complaints of pain. Neuro checks were initiated, and the physician was notified. X-rays were ordered and later revealed fractures of both femurs. The resident was not transferred to the hospital until several hours after the fall, despite ongoing pain and abnormal X-ray findings. There was a lack of documentation regarding the resident's pain and status updates between the time of the fall and the transfer to the hospital. Interviews with staff confirmed that the CNA was aware of the two-person assist requirement but proceeded alone due to lack of available help. Other staff members stated that the resident was unable to move himself in bed or reach for objects independently. The death certificate indicated that the resident died from blunt force trauma to the right thigh, with the manner of death listed as an accident resulting from a fall at the facility.
Deficiencies in Food Service Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 134 residents. During an initial tour of the food service area, several deficiencies were observed, including a soiled ceiling-mounted return-air-exhaust ventilation grill and dirty overhead light assembly plastic lens covers. Additionally, a half-gallon of lactose-free milk was found in a cooler without an effective open or discard date, contrary to the facility's date marking procedure. The can opener assembly was also noted to be soiled with encrusted food residue. Further observations revealed a broken atmospheric vacuum breaker on the dish machine room hand sink faucet assembly and a mechanical dish machine psi gauge reading outside the acceptable range during the final rinse cycle. In the facility's food service pantries, various issues were identified, such as a damaged microwave oven face plate, mineralized ice machine dispensing spouts, and soiled ventilation grills. These findings indicate a lack of adherence to the 2022 FDA Model Food Code, which requires regular cleaning and maintenance of food-contact surfaces and equipment. Record reviews of the facility's policies and procedures highlighted a General Kitchen Sanitation Policy and a Preventative Maintenance Program, both of which were not effectively implemented. The policies outlined the need for a written cleaning schedule, daily sanitation rounds, and monthly audits, as well as a maintenance schedule to ensure a safe and sanitary environment. However, the observed deficiencies suggest that these protocols were not adequately followed, leading to potential risks of cross-contamination and inadequate sanitization.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 138 residents. During an environmental tour of the facility's laundry service, it was observed that two padded floor mats were worn and attached to the flooring with duct tape, and the flooring surface adjacent to the washers was damaged. Additionally, the corridor carpeted surface was stained and soiled near resident rooms. These conditions increase the likelihood of cross-contamination and bacterial harborage. Further observations during a common area environmental tour revealed several deficiencies. In the 200 Hall, a clean linen cart cover was threadbare, and in the 300-400 Hall, chairs at the nursing station and activity room were damaged, exposing inner padding. The main dining room was missing a chair railing, and the physical therapy hand sink faucet was loose. In the 500 Hall, light lens covers were soiled, and a shower wand assembly was missing a vacuum breaker. The 600 Hall had a soiled fan and cabinetry with food residue, and the dining room kitchenette had broken cabinet drawers. An environmental tour of sampled resident rooms revealed multiple issues, including non-functional light assemblies, soiled air conditioning unit filters, damaged drywall and laminate surfaces, and soiled bedding. The facility's manual work order system did not have specific entries related to these maintenance concerns, indicating a lack of effective tracking and resolution of maintenance issues. The facility's policies on cycle cleaning, maintenance inspection, and routine cleaning and disinfection were not effectively implemented, contributing to the deficiencies observed.
Failure to Honor Resident's Choices in Daily Routine and Outdoor Access
Penalty
Summary
The facility failed to honor a resident's choices regarding his daily routine and outdoor access, leading to a deficiency. The resident, who is cognitively intact and has a history of multiple sclerosis, depression, bipolar disorder, and anxiety, expressed a strong desire to be assisted out of bed early in the morning, as he had been accustomed to being active early in his life. Despite his requests and a promise from the facility to adjust his morning routine, the resident continued to experience delays in receiving assistance, often being left in bed until after lunch. This situation contributed to his feelings of depression and frustration. Additionally, the resident, who has a physician's order allowing him to leave the facility, was consistently denied the opportunity to go outside independently in his motorized wheelchair. The facility's care instructions prohibited him from exiting the facility in his wheelchair, despite his expressed need for sunshine and fresh air, which he associated with his lifelong passion for the outdoors. The Director of Nursing acknowledged that residents should be allowed to get up at their requested time and be offered assistance to go outside, indicating a failure in the facility's practices to support resident self-determination and choice.
Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure proper oral care for a resident, identified as R81, who was admitted with diagnoses including atherosclerotic heart disease and essential tremor. R81 was cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status, and required setup or clean-up assistance for oral hygiene due to impairments in one upper and one lower extremity. Despite these needs, R81 reported that their teeth had not been brushed since admission, and they had not been provided with the necessary supplies to perform oral hygiene independently. Observations confirmed that R81's toothbrush was still in a sealed package, and no toothpaste was available in their room. Further investigation revealed that the facility's staff, including CNA N, did not offer the necessary setup assistance for oral care, as R81 was not feeling well on the morning of the observation. Documentation in R81's medical record indicated an order for the nurse to prepare a toothbrush for oral care after medication pass in the morning and at bedtime, which was marked as completed in the Medication Administration Record. However, R81 only received assistance to brush their teeth after the State Agency's involvement, highlighting a lapse in the facility's adherence to the prescribed oral care routine. The Director of Nursing confirmed that residents should receive oral care at least once a day, but R81's experience demonstrated a failure to meet this standard until external intervention occurred.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property, specifically clothing, from loss, which potentially affected the resident's psychological wellbeing. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported missing clothing items. Despite the resident's efforts to label his clothing to prevent loss, he was observed wearing a hospital gown due to a lack of personal clothing. The resident expressed frustration and embarrassment over the situation, indicating that he had to purchase new clothes with limited financial resources. The Director of Nursing (DON) was informed by the resident about a missing pair of grey pants but was not made aware of the extent of the missing clothing items. The resident claimed to have informed the DON multiple times about the missing clothes, but no formal grievance or concern form was filed, as the resident was unaware of the need to do so. The facility's grievance logs did not contain any documentation of the resident's complaints, highlighting a communication gap between the resident and the facility staff regarding the loss of personal property.
Failure to Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime as required by section 1150B of the Act. A resident with cognitive impairment and a history of anxiety disorder and dementia was documented in a nursing progress note as having verbally abused another resident and threatened physical harm. The note was authored by an LPN who later stated she did not recall the details of the incident and did not report the allegation. The Nursing Home Administrator confirmed she was unaware of the incident and stated that the expectation was to report any abuse allegations immediately. This sequence of events demonstrates that the facility did not ensure timely reporting of suspected abuse as required.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who was admitted with diagnoses including anxiety disorder, vascular dementia, and dementia with behavioral disturbances. The resident, who was cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, was documented in a nursing progress note as having verbally abused another resident and threatened physical harm. The note was authored by an LPN, who later stated she did not recall the details of the incident and did not report the allegation. The Nursing Home Administrator confirmed she was unaware of the incident and stated that the expectation is to report any abuse allegations immediately. No investigation into the alleged abuse was initiated by the facility.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the needs of two residents with cognitive impairments and behavioral issues. One resident, admitted with anxiety disorder, vascular dementia, and dementia with behavioral disturbances, was documented as cognitively impaired and known to ambulate independently with a walker. Multiple behavior and nursing notes over several months recorded this resident wandering into other residents' rooms, particularly during evening and nighttime hours, and requiring redirection by staff. Staff interviews confirmed that this resident frequently entered other residents' rooms, causing distress among peers, and that staff struggled to manage these behaviors, especially during times of limited staffing. Despite repeated observations and documentation of wandering and room entry behaviors, the resident's care plan did not include interventions to address or minimize these actions. Additionally, another resident with aphasia, who was rarely understood, had no care plan interventions to prevent the first resident from re-entering her room after a documented incident. The Director of Nursing confirmed the absence of care plan measures for these behaviors, indicating a lack of comprehensive planning to meet the residents' needs and ensure their safety and well-being.
Failure to Provide Scheduled Showers per Care Plan Due to Staffing Issues
Penalty
Summary
Two residents with cognitive intactness and significant physical limitations did not receive showers as scheduled per their care plans. Both residents were observed to be ungroomed and expressed dissatisfaction with the care provided, specifically noting that showers were not given on their scheduled days. Instead, staff offered bed baths, which the residents did not want, and when they declined the bed bath, it was documented as a refusal of a shower. The residents reported that this was a recurring issue and that their requests for showers were not accommodated, even on designated make-up days. Multiple direct care staff and CNAs confirmed that staffing levels were inadequate, particularly on the units where these residents resided, which had higher acuity and behavioral needs. Staff reported that due to insufficient staffing, they were unable to complete all required care tasks, including providing showers, oral care, and timely responses to call lights. Staff also described logistical challenges, such as having to cover adjacent units and being unable to monitor call lights in both areas, further impacting their ability to provide care as outlined in residents' care plans. Nursing leadership, including an RN and the DON, acknowledged that the expectation is to provide a shower to any resident who requests one and that offering a bed bath instead is not acceptable if the resident wants a shower. Documentation reviewed for both residents showed multiple instances where showers were not provided as scheduled, with some entries marked as "not applicable," "refused," or "bed bath" instead of a shower. The deficiency was substantiated through observation, resident and staff interviews, and record review.
Failure to Provide Sufficient Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and failure to provide scheduled showers for multiple residents. Several residents, all cognitively intact and requiring varying levels of assistance for mobility and personal care, reported long wait times for assistance, sometimes up to an hour. Residents described situations where staff would turn off call lights without providing the requested help and would not return, leading to residents remaining in soiled conditions for extended periods. Residents also reported that staff frequently complained about being short-staffed and told them they would have to wait for care. Multiple residents expressed dissatisfaction with the lack of consistent showers, stating that on scheduled shower days, staff would inform them that they were too busy and offer bed baths instead. Residents who declined bed baths in favor of showers were documented as having refused showers, despite their insistence that they wanted a shower and not a bed bath. This issue was reported as recurring, with residents stating that they were not offered showers on makeup days and that their personal hygiene needs were not being met as planned. Interviews with direct care staff and a staffing coordinator confirmed that staffing levels were determined by facility census rather than resident acuity. Staff reported being unable to complete all required care tasks, including showers, oral care, and timely response to call lights, due to insufficient staffing. Staff also described logistical challenges, such as having to cover multiple units separated by double doors, which prevented them from being notified of call lights in other areas. Staff consistently reported that the units in question housed residents with higher acuity and behavioral needs, further compounding the difficulty in providing adequate care with the available staffing.
Failure to Include Endocrinologist Coordination in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple serious health conditions, including Type II Diabetes and several malignant neoplasms. The resident was under the care of an endocrinologist for diabetes management, with specific instructions in the Electronic Medical Record (EMR) to contact the endocrinology clinic if the resident experienced frequent high or low blood sugar levels. However, the care plan dated January 20, 2024, did not include any intervention for communication and coordination with the endocrinologist, which was a critical component of the resident's diabetes management. During an interview with the Director of Nursing (DON), it was acknowledged that the care plan lacked an entry regarding communication and coordination with the endocrinologist. The DON noted that this was not typically included in care plans but recognized it as an area for improvement. The deficiency was identified through a review of the EMR and care plan, highlighting the potential for a lack of needed care due to the omission of this critical intervention.
Failure to Coordinate Diabetes Care with Endocrinology
Penalty
Summary
The facility failed to adhere to a physician's order for communication and coordination with an endocrinology clinic for the management of a resident's diabetes care. The resident, who had multiple malignant neoplasms and was receiving cancer treatment, had an order dated 3/22/24 to contact the endocrinology clinic if blood glucose levels were frequently high or low, with a target range of 100-200 mg/dl. Despite this order, the resident experienced consistently high blood glucose levels from 7/4/24 to 7/9/24, with no documentation indicating that the endocrinology clinic was notified during this period. Interviews with facility staff revealed a lack of clarity and coordination regarding the communication with endocrinology. A Nurse Practitioner mentioned that endocrinology was monitoring the resident closely due to their cancer treatment and steroid use, but was unsure of the frequency of contact with endocrinology. The Director of Nursing acknowledged the lack of documentation and expressed concern over the communication and coordination of care services with endocrinology. The deficiency was identified as a failure to follow the physician's order, resulting in unmanaged high glucose levels for the resident.
Medication Administration Failure Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to administer medications as ordered for a resident, resulting in the resident's dissatisfaction with care and eventual departure from the facility to seek medical treatment elsewhere. The resident, who had been admitted with diagnoses including an infection following a procedure and the presence of a prosthetic heart valve, was prescribed Vancomycin to be taken every six hours for Clostridioides Difficile. However, the Medication Administration Record indicated that the resident missed three doses of Vancomycin due to it being out of stock, as noted by the Licensed Practical Nurse (LPN) on duty. The resident expressed anger and dissatisfaction with the missed doses and ultimately decided to leave the facility against medical advice. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there was a misunderstanding regarding the availability of backup medication in the facility's automated medication dispensing system, PYXIS. Although the DON initially believed there was no backup medication available, a subsequent review of pharmacy records showed that there were indeed eight capsules of Vancomycin in stock at the time the doses were missed. This lack of awareness and communication among the staff led to the resident missing critical doses of medication, contributing to their decision to leave the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 605 citations issued within 25 miles in the last 12 months — including the 1 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 Ann Arbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glacier Hills | 1.6 mi | ★★★★★ | 0 | 0 |
| The Gilbert Residence | 3.4 mi | ★★★★★ | 0 | 0 |
| Villa At Willow Place | 3.7 mi | ★★★★★ | 18 | 0 |
| The Villa At Parkridge | 3.9 mi | ★★★★★ | 19 | 0 |
| Regency At Bluffs Park | 4.6 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.