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 Optalis Health And Rehabilitation Of Dearborn Heig during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors observed a food prep sink drain without the required 1-inch air gap, rust on the microwave interior frame and center area with potential to contact food, and a box of burgers left open to the air in the freezer. The Dietary Manager acknowledged the concerns, and facility policies cited requirements for safe food storage and air gaps for food-handling equipment.
Failure to update a resident’s meal-assistance care plan. A resident with dysphagia, impaired cognition, and malnutrition was observed eating and feeding self in their room, while the care plan still listed 1:1 feeding assistance and assistance with all meals. The RD stated the resident now only needed setup and encouragement, and the DON said the care plan should have been updated because the resident could feed self.
Failure to apply an ordered palm protector: A resident with severe cognitive impairment, muscle wasting and atrophy, cognitive communication deficit, and diabetes was observed with a contracted L hand while lying in bed, and no palm protector was present. The resident’s care plan and physician order directed the L hand palm protector to be worn during the day shift and removed in the evening for skin checks, but repeated observations showed no splint in place. The ADT said the resident would benefit from the palm protector, and the DON stated they were still looking into it and believed the resident was using it on a trial basis.
Failure to provide podiatry services occurred when a resident with severe cognitive impairment, Cerebral Infarction, Vascular Dementia, and Epilepsy was observed with yellow, extremely elongated toenails curling over on the left foot. The DON was unsure why the resident had not been seen, and the SW stated the spouse had requested podiatry care, the resident had been placed on the list multiple times, and reminder emails were sent to the podiatry provider, but the resident still was not seen.
Inadequate monitoring of lactulose therapy: A resident ordered lactulose via PEG for elevated ammonia levels did not have a recent ammonia level documented, and the medication was not available during a med pass observation. Record review showed the last ammonia lab was months earlier, while the MAR continued to document lactulose administration. The resident also had senna documented as given and daily bowel movements recorded, with PRN PEG laxative ordered but not administered.
Medication Left at Bedside Without Self-Administration Assessment: A resident with dementia and impaired cognition was observed multiple times with saline nasal spray on the overbed table, and the resident stated they gave it to themself. The record showed the resident lacked capacity to make medical decisions, and no medication self-administration assessment was found. An LPN said only one resident had self-administration approval, and it was not this resident; the DON stated bedside medication requires a self-administration assessment, including for OTC meds and nasal sprays.
Binding Arbitration Agreement Not Clearly Explained: The facility failed to ensure three residents understood the Binding Arbitration agreement they signed. Two residents with BIMS scores of 10/15 and 15/15, and another resident with a BIMS score of 15/15, did not recall agreeing to arbitration or understanding that it waived the right to judge, jury, or trial. The AD said the packet was left in residents’ rooms for review and described arbitration with a simple sibling analogy, but acknowledged they did not explain that it limited the right to resolve disputes through judge, jury, or trial.
Call Light Not Within Reach for Dependent Resident: A resident with a history of falls, severe cognitive impairment, and assistance needs for transfers and personal care was repeatedly observed in bed or in a wheelchair with the call light out of reach or misplaced. The resident was also seen without nonslip socks, with soiled linens after breakfast, and later seated at the nurse’s station appearing sleepy while dressed in a hospital-style gown. Staff reported the resident was confused, forgetful, and a fall risk, and the care plan stated the call light was to be within reach.
Failure to provide daily grooming and skin care for a resident who was unable to complete ADLs independently. The resident was observed on multiple occasions with white, scaly facial skin and dry skin residue on the shirt covering the neck and chest area, including wearing the same shirt on consecutive days. An LPN and CNA stated dry skin care should be provided as needed during daily hygiene care, and the DON acknowledged the residue and stated the resident's face and skin should be kept moisturized.
Failure to maintain heel pressure injury interventions. A resident with bilateral heel DTIs, a right femur fracture, and an order for bilateral heel protectors was repeatedly observed in bed with the heels resting on the mattress and the heel boots off and placed on a windowsill. The resident denied refusing the boots or repositioning and reported intermittent heel pain; the wound nurse confirmed the heel boots and right leg splint should be on while in bed, and the DON confirmed pressure injury interventions should be applied.
Failure to obtain ordered laboratory tests for two residents. One resident with cirrhosis had ordered CMP, MAG, Phos, and ammonia labs that were not completed when first ordered, and the resident later became lethargic and was sent to the hospital. Another resident with dementia and psychiatric diagnoses had a valproic acid level recommended by pharmacy and agreed to by the prescriber, but the lab was delayed until much later and returned low.
Unsanitary resident room equipment and ice machine drain issues: Surveyors observed dried tube feeding residue on a resident’s tube feeding pole, floor, and privacy curtain, along with stained pole feet in the room. Two ice machines also had drain tubes positioned below the required 1-inch air gap, and one drain had a black gel/mildew-like buildup. The Interim DON and Maintenance Director acknowledged the observations.
A resident with dysphagia and muscle wasting, requiring assistance with mobility, did not receive scheduled OT and PT sessions as ordered. Documentation and staff interview confirmed that several therapy sessions were missed before the resident was transferred to the hospital and did not return.
A CNA was observed using unsanitary methods to fill water cups with ice, including using bare hands and picking up cups from the floor. The NHA confirmed the procedure should involve a scoop, but no written policy existed for using bagged ice.
A resident with heart failure did not receive prescribed elastic bandage leg wraps, despite their delivery and documentation indicating they were applied. The ADON confirmed the discrepancy between documentation and actual care, highlighting a failure to follow physician orders.
A resident sustained a second-degree burn after spilling hot water from an unstable foam cup during a meal. The facility failed to serve hot beverages in stable, handled, thermal cups and did not adhere to safe temperature guidelines, with water temperatures reaching 164 degrees Fahrenheit. The resident, who had muscle weakness and coordination issues, was not adequately assessed or monitored for handling hot liquids, leading to the injury.
The facility's water management plan was found deficient as it lacked comprehensive documentation and necessary components to effectively reduce the risk of legionella and other pathogens. The Maintenance Director confirmed that only yearly legionella testing was conducted, with no results or prior documentation available. The Nursing Home Administrator acknowledged the plan's shortcomings, which increased the risk of waterborne pathogens affecting the 86 residents.
A resident sustained a second-degree burn from hot water, and the facility failed to update the care plan to prevent further incidents. Despite the burn, the resident continued to receive hot water in unstable foam cups at scalding temperatures. The care plan lacked interventions for meal tray setup, monitoring, or adaptive equipment, contrary to facility policy requiring updates after significant condition changes.
A resident expressed frustration and uncleanliness due to receiving only one shower since admission, despite not refusing any. The resident, who required maximal assistance and was cognitively intact, had been on infection precautions but did not receive a shower after coming off isolation. The facility's logs showed one shower and four bed baths in 30 days, contrary to the resident's preference and the facility's policy on maintaining hygiene.
A resident with impaired cognition and malnutrition did not receive a meal tray as ordered by the physician. The resident was observed without a lunch tray on several occasions, and staff confirmed the oversight. The Registered Dietitian noted the resident should receive a tray for pleasure and assistance with meals, but the diet was not updated in the system, stopping meal ticket printing.
A resident undergoing dialysis three times a week did not receive a lunch or snack from the facility, despite their care plan indicating the need for meals on dialysis days. The resident, who had severe malnutrition and significant weight loss, reported missing meals and being hungry until dinner. Facility staff confirmed the oversight, and the Nursing Home Administrator and Assistant Dietary Manager were unaware of the issue, despite having prepacked lunches available.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen during an initial observation conducted with the Dietary Manager on 02/04/2026 at 9:30 AM. Surveyors observed that the terminal end of the drain for the food prep area sink slanted down below the level of the floor drain and did not have a minimum one inch air gap. The Dietary Manager acknowledged the identified concerns would need to be rectified. Additional kitchen observations showed visible rust on the inside frame of the microwave opening along the bottom edge, extending a half or more from the inside rim, and a quarter-size rusted area in the center of the microwave, each with a potential to contact food. Surveyors also observed a box of burgers open to the air inside the freezer, and the Dietary Manager removed them. The facility policy on Food Storage stated that dietary staff and supervisors are responsible for ensuring food is stored, labeled, and used within recommended time guidelines to prevent food borne illness, and the Air Gaps policy stated that food prep sinks must discharge through an indirect waste pipe by means of an air gap of at least 1 inch.
Failure to Update Meal Assistance Care Plan
Penalty
Summary
The facility failed to update R6’s care plan related to meal assistance after the resident’s condition changed. R6 was admitted and later readmitted with diagnoses including nontraumatic acute subdural hemorrhage and severe protein-calorie malnutrition. The MDS noted impaired cognition and that R6 required setup or clean-up assistance for eating. The physician’s progress note documented dysphagia requiring a texture-modified diet, protein-calorie malnutrition, continued assisted feeding, and diet consistency precautions. However, the care plan still listed assistance with all meals and 1:1 feeding assistance, even though the RD stated R6 had initially needed 1:1 assistance but now only needed help setting up the meal and encouragement, and the DON stated the care plan should have been updated because R6 was able to feed themselves. During observations, R6 was seen eating lunch in their room without assistance on 2/04/2026 and again feeding themselves lunch on 2/06/2026. When asked about lunch, R6 reported eating in their room and described the meal. The care plan had not been revised to reflect the resident’s current level of meal assistance despite the change in condition and the facility’s policy stating care plans are revised when resident conditions change, when the desired outcome is not met, and when a resident is readmitted from a hospital stay.
Failure to Apply Ordered Palm Protector
Penalty
Summary
The facility failed to apply a palm protector per physician order and the resident’s care plan for one resident with severe cognitive impairment, muscle wasting and atrophy, cognitive communication deficit, and diabetes. On observation, the resident was lying flat on their back asleep, and the left hand was contracted. No palm protector was observed on the resident or near the bed during the observation. The resident’s record showed an active care plan directing that the left hand palm protector be worn during the day shift and removed at the end of the day shift for a skin check, along with an active physician order dated 11/17/24 for the left hand palm protector to be applied during the day shift and removed in the evening while the hand was observed for skin issues each day shift. Subsequent observations on multiple dates and times showed no splint on the resident’s left hand. The Assistant Director of Therapy stated the resident would benefit from a palm protector, and the DON stated they were still looking into it and thought the resident was using the palm protector on a trial basis.
Failure to Provide Podiatry Services
Penalty
Summary
Provide appropriate foot care was not met when the facility failed to provide podiatry services to one resident with severe cognitive impairment and dependence for activities of daily living. The resident was admitted with diagnoses including Cerebral Infarction, Vascular Dementia, and Epilepsy. During observation, the resident’s toenails on the left foot were yellow, extremely elongated to the length of the nail bed, and curling over. The resident was unable to respond when asked about seeing a podiatrist due to cognition. Record review showed the resident had not been seen by podiatry, and when the surveyor requested podiatry notes, the facility provided only a list of residents scheduled to be seen later. The DON was unsure why the resident had not been seen, and the Social Worker stated the spouse had requested podiatry care and the resident had been placed on the list in October and December, with reminder emails sent to the podiatry provider, but the resident still was not seen.
Inadequate monitoring of lactulose therapy
Penalty
Summary
The facility failed to ensure appropriate monitoring for lactulose ordered for a resident with elevated ammonia levels. During a medication pass observation, the LPN noted that lactulose was not available for administration. The order in the record showed lactulose oral solution 30 mL via PEG tube twice daily for ammonia level, with an original order date of 01/20/25. The last ammonia level found in the record was from 07/25/25, with a result of 79 and a normal range listed as 31-169, and the lab note dated 07/28/25 indicated no new orders were given. The MARs documented administration of lactulose since July 2025, but the record review showed no more recent ammonia level to support ongoing monitoring of the medication. The MAR for February 2026 also documented senna as given, and the resident had daily bowel movements documented over the last 30 days; GlycoLax was ordered as needed with no administration documented in February 2026. The DON documented speaking with the NP about lactulose, and the NP stated the resident had originally been placed on lactulose for an elevated ammonia level and that ammonia levels would be monitored weekly until in range, then continued based on labs and case-by-case review.
Medication Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure medication was not left at the bedside for a cognitively impaired resident, R118. On 02/04/2026, 02/05/2026, and 02/06/2026, R118 was observed with a bottle of Saline Nasal Spray on the overbed table, including once with the breakfast tray. R118 stated they administered it to themself. The record review documented that R118 lacked capacity to make medical decisions, and no medication self-assessment was found in the medical record. R118’s record showed admission to the facility with diagnoses of dementia, depression, and high blood pressure. The active care plan noted altered communication related to cognitive impairment and hard of hearing. The MDS assessment dated [DATE] indicated severely to moderately impaired cognition with a 6/15 BIMs score and the need for setup for meals. An LPN reported knowing of only one resident with self-administration of medication, and that it was not R118. The DON stated that if a resident was granted self-administration of medication, they would have a lock box, and if a resident was going to keep medication at the bedside, a self-administration assessment was needed, including for inhalers, OTC medications, and nasal sprays. Facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure residents received a clear understanding of its Binding Arbitration agreement for three residents reviewed. The agreement stated it was voluntary and that signing waived the right to have disputes decided by a judge, jury, or trial, with the arbitrator having sole jurisdiction and the decision being final and binding. However, interviews showed that R25, who had COPD, type II diabetes, heart failure, and a BIMS score of 10/15, did not recall signing the agreement and was not familiar with what binding arbitration meant; when told it would prevent disputes from being resolved by judge, jury, or trial, the resident stated they would never have agreed to it if that had been explained. R74, who had muscle wasting, type II diabetes, unspecified dementia, and a BIMS score of 15/15, also did not recall signing the agreement and stated they most likely would not have agreed to it if they had known it would prevent resolution through judge, jury, or trial. R20, who had a BIMS score of 15/15, reported not recalling entering into the agreement during a resident council meeting. The Administrator stated they were not familiar with the agreement and referred the surveyor to the Admissions Director. The Admissions Director reported that admission packets containing the Binding Arbitration agreement were dropped off in residents’ rooms for review, and then the resident or representative would later meet with staff to sign the documents. When asked how the agreement was explained, the Admissions Director said they gave a simple explanation comparing arbitration to siblings sitting at a table until they worked things out, and acknowledged they had never thought of explaining that the agreement limits the right to resolve disputes through a judge, jury, and trial.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a dependent resident, R129, who was reviewed for falls. On 02/04/2026, R129 was observed lying on their back in bed with the head of the bed elevated, dressed in a hospital-style gown, with the tray table to the left side of the bed. The call light was not in reach and was looped over the headboard. The gown was hanging down off the bare right shoulder. The record showed R129 had fallen onto their knees on 02/03/26. On 02/05/2026, R129 was again observed in bed without nonslip socks, with breakfast eaten and the blanket and sheets soiled with stool and breakfast items. The water cup was dated 2/4, and the call light was behind the head of the bed, partially looped over the headboard and down between the nightstand and bed, with the call button on the nightstand. Later observations showed R129 seated in a wheelchair at the nurse’s station, intermittently falling asleep with the head down and eyes closed, while dressed in a hospital-style gown and with a blanket over the legs and feet. On 02/06/2026, R129 was observed supine in bed with the head of the bed elevated about 45 degrees, feeding themself breakfast, while the call light button was behind the head of the bed and on the floor. CNA C reported R129 had confusion but was redirectable. CNA D reported R129 needed help dressing, could feed themself, could use the call light, could make needs known, but was forgetful and thought they could stand on their own; CNA D also stated R129 was a fall risk and not very steady on their feet. The record documented diagnoses including history of falling, muscle wasting, heart failure, and overactive bladder, and the MDS documented severe cognitive impairment and assistance needs for transfers, standing, and personal hygiene. The active care plan identified fall risk and documented that the call light was to be within reach.
Failure to Provide Daily Grooming and Skin Care
Penalty
Summary
The facility failed to maintain appropriate grooming and skin care for one resident, R104, who was unable to perform activities of daily living independently. On 02/04/2026, R104 was observed lying in bed with white, scaly skin on the face, and the residue was covering the front of the resident's black t-shirt. On 02/05/2026, R104 was again observed in bed finishing breakfast wearing the same black t-shirt from the previous day, with continued dry scaling skin on the face and scaling residue covering the neck and chest area of the shirt. On 02/06/2026, R104 was observed at bedside with the chest of the shirt covered with dry skin residue. During interviews on 02/06/2026, an LPN stated dry skin should be treated daily as needed, and a CNA stated dry skin care is completed as needed during daily grooming and hygiene care, not only after showers. The DON observed R104 with the surveyor and acknowledged the dry skin residue on the resident's shirt, stating the expectation was that the shirt would be kept clean and free of debris and that the resident's face and skin should be kept moisturized. The facility's ADLs policy stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including assistance with hygiene, bathing, dressing, grooming, and oral care.
Failure to Maintain Heel Pressure Injury Interventions
Penalty
Summary
The facility failed to implement interventions for heel pressure sores for one resident with bilateral deep tissue injuries to the heels. The resident had diagnoses including a right femur fracture and deep tissue injuries of both heels, and the care plan called for repositioning and floating the heels or wearing heel boots. A physician order dated 01/27/26 directed staff to place bilateral heel protectors, and a wound consult note dated 01/31/26 documented pressure-induced deep tissue damage of the right heel measuring 3.6 cm x 2.8 cm and the left heel measuring 2.5 cm x 3.0 cm, with heel lift boots while in bed. During multiple observations, the resident was found in bed with the head of the bed elevated and the heels resting on the mattress without heel boots or another device to elevate the heels off the bed surface. The heel boots were repeatedly observed off and placed on the windowsill at the foot of the bed. The resident reported the boots had been removed and not put back on, denied refusing the boots or repositioning, and reported intermittent heel pain and later pain from the hip to the feet. The wound care nurse confirmed the heel boots and the right leg splint should be on while in bed, and the DON confirmed pressure injury interventions should be applied to improve wound healing.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide ordered laboratory services for two residents. For one resident with cirrhosis of the liver and intact cognition, physician orders dated 12/22/25 included CMP, magnesium, phosphorus, and ammonia levels, but the ammonia and other ordered labs were not completed when first ordered. The record showed the labs were reordered on 1/6/26, and the resident later developed increased lethargy and was transferred to the hospital the same day. The DON stated the process was not done correctly because the order was never placed into the lab book, so the lab technician would not know there was an order. For a second resident with vascular dementia, schizoaffective disorder, and bipolar disease, a consultant pharmacist recommended a valproic acid level for clinical monitoring, and the prescriber agreed on 12/3/25. However, the lab was not drawn until 2/4/26, and the result was low at 8.57 with a reference range of 50.0-100.0. The DON stated the pharmacy recommendation should have been addressed earlier and acknowledged the delay in obtaining the lab.
Unsanitary resident room equipment and ice machine drain issues
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in two resident rooms and two ice machines. On 02/04/26, surveyors observed the drain tube for the ice machine on the 300 unit with a circumferential buildup of a black gel/mildew-like substance at the distal end where it entered the drain, and the distal end of the drain was positioned below the rim level of the drain from the floor without the required one-inch air gap. On 02/05/2026, the dual drain tube from the back side of the ice machine off the service hall/100 hall was also observed below the level of the drain cup and without the minimal one-inch air gap, and the front tray was mounded with ice. In room [ROOM NUMBER]B, the tube feeding pole was observed on 02/04/2026 and again on 02/05/2026 with multiple dried areas of tube feeding liquid on the base, shaft, and floor, and the spots on the floor could not be easily scraped off. The privacy curtain in the same room had three yellow half-dollar sized stains and multiple milk chocolate colored dry drip stains along the left edge and left center area, and the feet of the tube feeding pole had multiple tan dried tube feeding spots. On 02/06/2026, the Interim DON observed the tube feeding pole residue and acknowledged that the equipment and area should be kept clean and not left to dry. The Maintenance Director also acknowledged the air gap observations and the needed repair of the drain lines and ice machine maintenance. Facility policies titled Homelike Environment review and Air Gaps stated that residents are to be provided a safe, clean, comfortable, and homelike environment and that ice machines require air gaps to prevent backflow and contamination.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) and Physical Therapy (PT) services as ordered for one resident. The resident was admitted with diagnoses of dysphagia and muscle wasting, and required staff assistance with bed mobility and transfers. According to the medical record, the resident was scheduled to receive PT and OT five days a week during a specified certification period. However, documentation showed that the resident missed OT sessions on two days and PT sessions on three separate days within that period. The Director of Rehabilitation confirmed that the resident missed several therapy sessions before being transferred to the hospital and did not return to the facility. The therapy services agreement required therapy to be provided according to the attending physician's written orders and plan of care, but these services were not consistently delivered as scheduled for the resident.
Unsanitary Ice Handling Practices
Penalty
Summary
The facility failed to maintain sanitary practices while filling water cups with ice, which had the potential to affect all 104 residents who drink water in the facility. During an observation, a Certified Nursing Assistant (CNA) was seen using an empty cup to scoop ice from a bag and then using their bare hand to scoop ice into empty cups. Additionally, some cups fell to the floor, and the CNA picked them up, filled them with ice and water, and did not respond when asked if these cups would be used for residents. The Nursing Home Administrator (NHA) confirmed that the procedure should involve using a scoop from a cooler, but there was no written policy for using bagged ice.
Failure to Follow Physician Orders for Elastic Bandage Application
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring elastic bandage leg wraps. The resident, who was admitted with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure, expressed concerns during a care conference about not receiving timely care, including the application of elastic bandage wraps. Despite the delivery of the wraps on a Sunday, they remained unused and unopened by the following Tuesday, as observed during a visit. The resident's Treatment Administration Record indicated that the wraps were to be applied daily at 9:00 AM and removed at bedtime, but this was not done. The Assistant Director of Nursing confirmed that the order was documented as completed but was not actually provided to the resident. The facility's policy on medication administration emphasizes the importance of following physician orders and documenting medication administration accurately. However, in this case, the documentation did not reflect the actual care provided, leading to a deficiency in the resident's treatment plan.
Resident Burned Due to Unsafe Hot Beverage Service
Penalty
Summary
The facility failed to ensure that a resident, identified as R132, was served hot beverages in a stable, handled, thermal cup, and provided with proper meal setup. This deficiency resulted in an Immediate Jeopardy situation when R132 sustained a second-degree burn after spilling hot scalding water for tea on themselves. The incident occurred during a lunch meal when R132 attempted to place a tea bag into a foam cup without a lid, causing the hot water to spill onto their blanket, shirt, and skin, leading to a burn on their abdomen. Observations and interviews revealed that the hot water served to R132 was at a dangerously high temperature, with measurements taken at 164 degrees Fahrenheit on their lunch tray and 184.6 degrees from the kitchen hot water dispenser. Despite the facility's policy stating that hot liquids should be served at temperatures between 130 to 160 degrees, the actual temperatures exceeded these limits, posing a risk of burns. Additionally, the facility's investigation indicated a lack of consistent use of stable thermal mugs with handles, as R132 reported that hot beverages were often served in unstable foam cups. R132's medical history included conditions such as coronary artery disease, kidney disease, muscle wasting, and repeated falls, requiring assistance with eating and transfers. Despite being assessed as cognitively intact, R132 had muscle weakness and coordination issues, which may have contributed to the incident. The facility's failure to adhere to safe practices for serving hot beverages, combined with inadequate assessment and monitoring of R132's ability to handle hot liquids, led to the burn injury and the Immediate Jeopardy finding.
Removal Plan
- Resident #132 remains a resident of the facility and is being served their hot liquids in a stable thermal cup with a handle and is being offered assistance with hot liquids.
- Like residents have been audited to ensure their liquids are being served in a stable, handled, thermal cup and staff are offering and/or providing assistance with set-up as needed.
- Dietary staff have been re-educated to ensure hot liquids are being served in a stable, handled, thermal cup. Dietary staff has also been re-educated on ensuring hot liquids are being serviced at a temperature less than 160 degrees Fahrenheit. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty.
- LPN/RN/CENA has been re-educated to ensure when meals are served resident with hot liquids are in a stable, handled, thermal cup and they are offering and/or providing assistance when serving hot liquids as needed. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty.
- An Ad Hoc QA Committee meeting was held with the Medical Director and IDT to discuss the deficient practice and plan to ensure compliance. The NHA/Designee will conduct audits to ensure that hot liquids are served in a stable, handled, thermal cup. The NHA/Designee will audit to hot liquid temperature logs to ensure temperatures are less than 160 degrees Fahrenheit prior to leaving the kitchen. Audits will be completed weekly and monthly. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator is responsible for maintaining compliance.
- The Administrator is responsible for sustained compliance.
Deficient Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to implement an effective water management plan to reduce the risk of legionella and other opportunistic pathogens in its plumbing system. During a survey, it was found that the water management plan provided by the Maintenance Director (MD C) only included a policy on safe water temperature and weekly temperature logs for specific areas, such as toilets in resident rooms, dish machines, laundry, and kitchen hand sinks. Additionally, the plan contained a monthly log of eyewash station flushes, which was unsigned. The Maintenance Director confirmed that the facility's water is tested yearly for legionella by an outside company, but they did not have the results for the current year's test or documentation of prior tests. Furthermore, the only prevention measures in place between these yearly tests were checks of water temperatures, and there was no flow mapping of the facility's plumbing included in the plan. The Nursing Home Administrator (NHA) acknowledged that the water management plan did not include all necessary components as outlined in the facility's instructions. The NHA stated that the Maintenance Director was responsible for conducting daily audits of water temperatures, checking for legionella twice a month, and inspecting fixtures for smells or abnormalities. However, the NHA confirmed that the water management plan lacked comprehensive documentation and did not meet the required standards. This deficiency increased the potential risk of waterborne pathogens spreading within the facility, posing a threat to the respiratory health of the 86 residents.
Failure to Update Care Plan After Resident Burn Injury
Penalty
Summary
The facility failed to update a resident's care plan after the resident sustained a second-degree burn on their abdomen from spilling hot water during a meal. Despite the incident, the care plan did not include new interventions to prevent further burns, such as meal tray setup, increased monitoring, or the provision of adaptive equipment. Observations revealed that the resident continued to receive hot water in foam cups, which were unstable and often served at temperatures above the scalding point, placing the resident at risk for additional burns. The resident expressed concern about the stability of the foam cups and the temperature of the hot water, indicating fear of another incident. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not done in this case. The interdisciplinary team did not implement necessary changes to the care plan to address the resident's burn injury and prevent future occurrences, as evidenced by the continued use of foam cups and the lack of temperature checks before serving hot beverages.
Failure to Provide Showers Per Resident Preference
Penalty
Summary
The facility failed to provide and document showers according to the preferences of a resident, identified as R132, who was unable to perform activities of daily living independently. R132 expressed feelings of frustration and uncleanliness due to receiving only one shower since their admission to the facility, despite not refusing any showers. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 13/15, required maximal assistance with bed mobility, transfers, and showers. The resident had been on infection precautions earlier in their stay but had not received a shower even after coming off isolation precautions. The facility's shower logs indicated that R132 received one shower and four bed baths in the last 30 days, with one recorded refusal. The resident and their family member both reported dissatisfaction with the care provided, as bed baths were not considered an adequate substitute for showers, especially given the resident's history of accidents during infections. The facility's policy on Activities of Daily Living, revised in December 2023, stated that residents unable to carry out activities of daily living independently should receive necessary services to maintain good hygiene, including appropriate support and assistance with bathing.
Failure to Provide Meal Tray Per Physician's Order
Penalty
Summary
The facility failed to provide a meal tray per physician's order for a resident diagnosed with Unspecified Protein-Calorie Malnutrition and Cerebral Infarction. The resident, who had impaired cognition and was dependent on staff for bed mobility and transfers, was observed without a lunch tray on multiple occasions. A Certified Nursing Assistant noted that the resident used to receive a pleasure tray but had not received one for the past few days. The Registered Dietitian confirmed that the resident should receive a tray for pleasure and 1:1 assistance with meals, with documentation of intake, but acknowledged the resident was not receiving the tray as required. The issue was identified during a Quality Assurance meeting, where it was revealed that the diet was not updated in the computer system, resulting in the cessation of printing meal tickets for the pleasure tray. The facility's policy on Nutritional Management did not address the delivery of pleasure trays, contributing to the oversight. The deficiency highlights a lapse in ensuring the resident's nutritional needs were met as per the physician's orders.
Failure to Provide Meals for Dialysis Resident
Penalty
Summary
The facility failed to provide a lunch and/or snack for a resident (R6) who required dialysis care. R6, who was observed to be thin and gaunt, reported that they did not receive a lunch or snack on their dialysis days, which occurred three times a week. R6 attended dialysis from 10:30 a.m. to 1:00 p.m., missing the facility's lunch service, and stated they were hungry until dinner time. Despite R6's requests for food, they did not receive any, and their care plan indicated that a meal or snack should be sent with them to dialysis. R6's medical history included kidney failure, heart failure, and severe protein-calorie malnutrition, with a significant weight loss noted. The facility's staff, including a CNA and an LPN, confirmed that they did not provide R6 with a lunch or snack before leaving for dialysis. The Nursing Home Administrator and the Assistant Dietary Manager were unaware of the issue, despite having prepacked lunches available for dialysis residents. The facility's policy on hemodialysis care required the provision of meals or snacks on dialysis days, but this was not adhered to, leading to the deficiency. The lack of communication and follow-through by the staff resulted in R6 missing meals on dialysis days, contrary to their care plan and dietary needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dearborn Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four Chaplains Nursing Care Center | 2.4 mi | ★★★★★ | 8 | 0 |
| Fountain Bleu Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 11 | 0 |
| Imperial, A Villa Center | 3.8 mi | ★★★★★ | 10 | 1 |
| Maple Manor Rehab Center | 4.8 mi | ★★★★★ | 0 | 0 |
| The Orchards At Wayne | 5 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.