Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 The Orchards At Harper Woods during CMS and state inspections, most recent first.
Exterior Dumpster Area Not Kept Clean: The facility failed to keep the exterior trash refuse area clean when surveyors observed a pile of assorted trash items on the ground behind the dumpster sitting in stagnant standing water. The Maintenance Director confirmed the trash buildup, and the facility policy required the building grounds to be kept free of trash, rubbish, debris, and unused equipment or furniture.
Missed showers and lack of feeding assistance: Three residents did not receive showers as scheduled or at their preferred frequency, with multiple missed bathing episodes not documented as completed and no progress notes explaining the omissions. One resident with cerebral infarction, one with spina bifida, and one with HF reported not getting regular showers and described feeling unclean or worried about skin and odor. In addition, a resident with Parkinson's disease and seizures, ordered for 1:1 meal assistance, was observed with an untouched lunch tray and no staff providing set-up or feeding help, despite RD confirmation that the resident needed assistance.
Missing Pressure Ulcer Care Plan: A resident with stroke, weakness, and vascular dementia had a stage 2 pressure ulcer identified on the MDS, but the EMR did not show a pressure ulcer care plan with goals, interventions, or desired outcomes. The resident was observed in bed on an air mattress with the pump off, and staff interviews confirmed that residents with skin issues should have a wound-specific care plan in place.
Failure to Update Fall Care Plan After Resident Fall: A resident with COPD and dementia slid from a wheelchair to the floor and was assessed with no injuries noted, but the fall care plan was not revised to add any new interventions after the incident. The resident had moderately impaired cognition and needed assistance with all ADLs except eating, and the facility policy stated the IDT would review and modify the plan of care to reduce repeat falls.
Failure to follow ordered protective devices and skin treatment orders. One resident with impaired cognition and mobility needs did not have ordered heel protectors in place despite an active order, and another resident with dementia and hand contractures did not have ordered bilateral palm protectors in place during repeated observations. A third resident had documented skin breakdown, including an open area on the thigh and coccyx MASD, but no corresponding treatment order was found in the physician orders.
Wander Guard Not Checked or Replaced: A resident with Major Depressive Disorder and Psychotic Disorder with Delusions had a wander guard order for placement, function, testing, and expiration checks, but the order was not entered correctly and did not appear on the TAR. Staff could not find documentation that the device was being checked or tested, and the DON and ADON confirmed the device had expired over a year earlier and would not activate the door alarm if the resident attempted to elope.
Improper medication storage and self-administration were observed for a resident. A surveyor found a medication cup with about 10 pills on the resident's bedside table while the resident was not present in the room, and the resident later said they had planned to take the meds after using the bathroom. The DON observed the meds and had the resident take them in the DON's presence. Record review showed the resident was cognitively intact, required supervision for ADLs, and had no documentation authorizing self-administration; the facility policy allowed self-administration only with physician authorization.
The facility failed to follow dentist recommendations for follow-up dental care for two residents. One resident with impaired cognition had a dental consult recommending outside comprehensive care, but the DON reported no email with the recommendation was received. Another resident with intact cognition had worn down and missing teeth, reported asking to see a dentist, and had annual exam recommendations for cleaning, a hygienist visit, and periodic oral care that were not documented as completed; the Scheduler said no order was received to arrange the follow-up.
A resident with intact cognition and COPD experienced a verbal altercation with a nurse after a delay in receiving pain medication, during which both parties exchanged derogatory language. In a separate incident, two residents with impaired cognition were involved in a physical altercation, resulting in one sustaining a bleeding lip and facial redness. Staff did not maintain professionalism or effectively deescalate these situations, leading to both verbal and physical abuse.
The facility did not maintain RN coverage for eight consecutive hours daily, affecting all 132 residents. Staffing data revealed low weekend staffing and multiple dates without RN coverage. The Staff Scheduler cited hiring and retention challenges, while the DON emphasized the expectation for adequate coverage. The facility's policy requires staffing based on resident acuity, which was not met.
The facility failed to ensure CNAs completed the required 12 hours of in-service education annually for three CNAs. CNA E, CNA F, and CNA G did not receive the mandated training. Staff Developer B, new to the position, acknowledged being trained differently on fulfilling the CNAs' training requirements. The DON expected CNAs to meet their required training hours, as indicated in the facility's assessment.
The facility failed to maintain sanitary conditions for residents receiving tube feeding, as observed in three residents. Tube feeding poles and floors were found with dried formula over several days, indicating a lack of proper cleaning. The residents had severe cognitive impairments and were dependent on staff for daily activities. The Director of Nursing stated that nurses and housekeeping were responsible for cleaning spills, but the facility's cleaning procedures were not followed.
A facility failed to update a resident's care plan after a fall, despite multiple observations of the resident in unsafe conditions. The resident, with a history of Acute Respiratory Failure, Dementia, Anxiety, and Macular Degeneration, was found in various states of neglect, such as being halfway off the bed and walking barefoot. The care plan had not been revised since the previous year, contrary to the facility's policy requiring timely updates after incidents.
A resident with epilepsy and dysphagia was not provided with necessary adaptive equipment, specifically a sippy cup, despite a physician's order and facility policy. The resident struggled to drink from a foam cup, and staff interviews revealed a lack of follow-through in reordering the required equipment.
A resident with Cellulitis and Peripheral Vascular Disease did not receive documented skin treatments as ordered, with multiple dates missing from the Treatment Administration Record. The resident's right leg was observed with an undated bandage, and the DON confirmed that treatments were expected to be completed as ordered.
A facility failed to provide adequate pressure ulcer care for a resident with severe cognitive impairment and total dependence on staff. The resident was observed lying on their backside without necessary offloading interventions, despite being at high risk for skin breakdown. The resident's pressure ulcer progressed to an unstageable stage, and prescribed treatments were not consistently documented as completed. The DON confirmed the need for repositioning every two hours, indicating a lapse in adherence to the care plan and facility policy.
A resident with limited mobility and medical diagnoses of dysphagia and cerebral infarction was observed without the prescribed bilateral elbow/hand splint on two occasions. The facility staff, including the DON and Restorative Nurse, showed a lack of clarity regarding the responsibility for applying the splint, and no application schedule was provided, despite requests.
The facility failed to serve meals at a palatable temperature for three residents, leading to dissatisfaction. One resident reported cold and hard vegetables, while another stated all meals were not good. A third resident mentioned insufficient portions when the food was good. The resident council noted complaints about cold food and prolonged food cart presence. The facility's policy acknowledged temperature drops but did not adequately address them.
The facility failed to obtain consent or declination for influenza and pneumococcal immunizations for two residents. One resident's responsible party refused vaccinations, but documentation was missing. Another resident's consent sheet lacked signatures, and a disconnected phone line hindered obtaining consent. Both residents had significant medical conditions and required staff assistance.
The facility failed to document COVID-19 vaccination consent or declination for two residents. One resident's refusal was known but not documented, while another's consent attempt was hindered by a disconnected phone line, with no follow-up. Both residents had significant medical conditions and required staff assistance, yet the facility did not maintain required documentation as per policy.
A resident faced financial management issues due to an expired driver's license, limiting their ability to access funds and pay bills. The facility failed to assist in renewing the license, leading to a deficiency in resident rights as the resident was pressured to fill out an ACH form under threat of discharge.
A resident was not readmitted to the facility after hospitalization despite being cleared for return, due to perceived aggressive behavior. The facility failed to provide proper notice for a facility-initiated discharge, and did not communicate adequately with the resident's guardian or the ombudsman. The necessary discharge notice was not completed, leading to a deficiency citation.
The facility failed to provide fresh water in a timely manner, as observed with several residents having warm, dated water cups from the previous night. Residents expressed dissatisfaction with the lack of fresh water, and the facility's hydration policy was not followed. Despite this, the DON was unaware of any issues, indicating a communication gap.
A resident reported verbal abuse by a CNA, who referred to their buttocks derogatorily and refused care. The resident, admitted with multiple pelvic fractures, had previously informed staff of the CNA's behavior. The DON and NHA were notified, leading to the CNA's suspension and termination.
The facility failed to ensure call lights were accessible and promptly answered for two residents. One resident was without a call light cord, making it impossible to call for assistance, while another resident's activated call light went unanswered for over 20 minutes. The DON was unsure if rounds were completed to ensure call light functionality and accessibility, contrary to the facility's policy of prompt response.
The facility failed to maintain a sanitary environment, affecting all residents. Observations showed dirty linen and trash left in rooms and common areas, causing foul odors. Staff interviews revealed inconsistencies in responsibilities for removing soiled materials, contrary to facility policy.
A resident with Juvenile Rheumatoid Polyarthritis, dependent on staff for ADLs, did not receive scheduled showers due to a misunderstanding of their shower schedule. Despite a sign indicating shower times, the resident reported not receiving showers, and documentation showed several instances marked as not applicable. The DON confirmed the resident's showers were missed due to a staff error in understanding the schedule change.
A resident with diabetes and neuropathy experienced pain due to long toenails, as the facility failed to provide timely podiatry care. Despite being admitted months earlier, the resident was not seen by podiatry until much later, with a missed visit in between. The facility lacked a written policy for podiatry care, and documentation was insufficient, leading to a delay in necessary foot care.
Exterior Dumpster Area Not Kept Clean
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a clean manner. On 5/5/26 at approximately 9:00 AM, the exterior dumpster area was observed with a pile of various trash items on the ground behind the dumpster, and the trash was sitting in a pool of stagnant, standing water. When questioned later that day, the Maintenance Director confirmed the trash buildup and stated that one of his staff had already gone out and cleaned it up. Review of the facility’s undated Physical Plant Exterior Maintenance policy noted that the building grounds should be kept free of trash, rubbish, debris, and unused equipment or furniture, with periodic cleaning of problem areas.
Missed showers and lack of feeding assistance
Penalty
Summary
The facility failed to provide showers as scheduled and per resident preferred frequency for three residents and failed to provide set up and feeding assistance for one resident. One resident with cerebral infarction and left hemiplegia, whose MDS indicated intact cognition and dependence on staff for bathing, was scheduled for showers twice weekly, but of ten scheduled showers only two were documented as completed and one as refused; the remaining seven had no shower sheets completed, and five were marked Not Applicable in the EMR without any progress note explanation. The resident reported they preferred showers, had not been given an explanation for missed showers, and stated they felt "No good" when they did not get one. A second resident with spina bifida and a history of skin infection, whose MDS indicated intact cognition and maximal assistance for bathing completion, reported they were scheduled for showers twice weekly but did not receive one as expected. Review of the shower schedule, shower sheets, and EMR bathing task record showed that five of eleven scheduled showers were not documented as completed, and there were no progress notes addressing missed or refused showers. The resident stated they preferred twice-weekly showers and worried about smelling poorly and about their skin when showers were not provided. A third resident with heart failure and a recent fall, whose MDS indicated intact cognition and moderate assistance for bathing completion, was scheduled for showers twice weekly but had five of eleven scheduled showers not documented as completed, with EMR bathing tasks recorded as Not Applicable on two dates and no progress notes addressing missed showers. In addition, a resident with Parkinson's disease and seizures, with impaired cognition and an active order for 1:1 assist with meals, was observed with an untouched lunch tray and no staff assisting with feeding, and on another observation the tray remained unopened and unattended. CNA staff reported the feeding assistance was not listed on the tray ticket, while the RD stated the resident needed 1:1 feeding assistance and set-up help, including removing lids and opening cartons.
Missing Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to develop a comprehensive pressure ulcer care plan for R35 that included goals, interventions, and desired outcomes. R35 was observed lying in bed on an air mattress, and the air mattress pump device was resting face down on the floor near the foot of the bed; when RN F was asked if the pump was on, the device was observed to be off. R35 was admitted to the facility on 10/01/2024 with diagnoses of cerebral infarction (stroke), weakness, and vascular dementia, and the most recent quarterly MDS showed a BIMS score of 99, indicating the resident was not able to complete the mental status interview. Review of the EMR showed that section M of the MDS identified one stage two pressure ulcer that was not present on admission. Further review of the EMR did not reveal a care plan for management of pressure ulcers. During interview, the Wound Care LPN stated it was standard procedure for every resident with a skin issue to get a care plan for it, and the ADON stated that a pressure ulcer care plan specific to each resident's wound care needs should be in place, especially when it is actively being treated. The facility policy on comprehensive care planning stated that the comprehensive care plan must be patient centered and describe the necessary care and services for each resident.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and implement specific interventions on a resident’s fall care plan after the resident fell. On 3/1/2026, the resident was observed sitting in a wheelchair and slid down from the chair onto their buttocks, then was found sitting on the floor and assisted back to the wheelchair. The incident/accident report stated the resident was assessed head-to-toe, vital signs were obtained, and no injuries were noted. A review of the resident’s fall care plan and interventions showed that no additional fall interventions had been added after the fall. The resident, identified as R41, had diagnoses including COPD and dementia, and the most recent MDS showed moderately impaired cognition and dependence for all ADLs except eating. During interview, the ADON stated that after a fall, nursing should complete an assessment and an additional intervention should be added to the care plan to avoid another fall. The facility policy titled Fall Management Guidelines stated that the IDT will review and modify the plan of care to minimize the risk of repeat falls.
Failure to Follow Ordered Protective Devices and Skin Treatment Orders
Penalty
Summary
The facility failed to follow physician-ordered heel protectors for one resident and bilateral palm protectors for another resident. One resident with hypertension, peripheral vascular disease, impaired cognition, and assistance needs for bed mobility and transfers had an active order for heel protectors while in bed as tolerated, but observations on multiple days found no heel boots in place. The resident stated the heel boots had been taken away and given to a roommate, and a CNA reported being unable to find them. The TAR showed documentation that the heel protectors had been applied on several days, but direct observations did not match the order. The facility also failed to implement an order for bilateral palm protectors for a resident with dementia, anxiety disorder, impaired cognition, and dependence for bed mobility and transfers. The resident had contractures to both hands and an order for palm protectors at all times except during hygiene care, yet repeated observations found no palm protectors in place. Staff gave conflicting information, with one CNA stating restorative staff applied and removed them, while restorative staff said the resident was no longer on the restorative program and the order was probably old. In addition, for another resident admitted with severe protein calorie malnutrition and anemia, a progress note documented an open area on the left thigh and a later skin note documented coccyx MASD with a treatment recommendation, but the physician orders did not include a treatment order related to the open area.
Wander Guard Not Checked or Replaced
Penalty
Summary
The facility failed to check and replace a wander guard for one resident. The resident was admitted with Major Depressive Disorder and Psychotic Disorder with Delusions, and the MDS assessment showed a BIMS score of 99, indicating the resident was unable to complete the assessment and required staff assistance with bed mobility and transfers. The physician order for the wander guard directed staff to check placement, working properly, test, and expiration date, but the order was not entered correctly and did not appear on the TAR for those checks. During the survey, staff could not provide documentation showing the wander guard was being checked or tested for functionality. The DON confirmed no documentation could be found, and an LPN stated the device checks were supposed to appear on the TAR but did not for this resident. The ADON stated that if the order had been entered properly, staff would have known the device expired over a year earlier, and reported that an expired or nonworking wander guard would not activate the door alarm if the resident attempted to elope. The facility policy titled Elopement did not address wander guard devices.
Improper Medication Storage and Self-Administration
Penalty
Summary
The facility failed to properly store medications for one resident, R123, during a survey observation. On 05/05/2026 at 10:54 AM, the surveyor entered R123's room and observed a medication cup containing approximately 10 pills on the resident's bedside table while the resident was not visibly present. R123 then exited the bathroom and stated they were going to take the medications but had to use the bathroom first. At 11:03 AM, the DON observed the medications in the room and requested that the resident take them in the DON's presence; the DON also asked why the medications had not been taken, and the resident again stated they had to use the bathroom first. Record review showed that R123 was admitted on 4/4/23 with diagnoses including heart disease, anxiety, and hyperlipidemia, was cognitively intact, and required supervision for activities of daily living. The record did not show documentation that R123 was authorized to self-administer medications. On 05/06/2026 at 12:00 PM, the DON told the surveyor that R123's assigned nurse was a newer nurse. The facility's Medication Administration and General Guidelines policy stated that medications are to be prepared, administered, and recorded only by authorized personnel, and that residents may self-administer medications only when specifically authorized by the attending physician and in accordance with policy.
Failure to Complete Recommended Dental Follow-Up
Penalty
Summary
The facility failed to follow dentist recommendations for follow-up dental appointments for two residents. One resident, admitted with end stage heart failure and anemia and assessed with impaired cognition, was observed in bed eating lunch and noted to have missing teeth. A dental consult documented that the resident should be seen by an outside dentist, likely in a hospital setting, for comprehensive care including extractions, fillings, cleanings, and radiographs because a thorough exam could not be completed and the resident could not articulate dental concerns. The DON stated the facility normally receives an email with dental recommendations and enters orders, but reported they never received an email regarding this recommendation. The second resident, admitted with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes, and major depressive disorder, was observed with many worn down and missing teeth and stated they needed implants and had asked staff to see a dentist but had not seen one yet. The resident had intact cognition and reported not recalling a dental visit that year, stating they had been told someone would come to clean their teeth but that did not happen. The most recent annual dental exam recommended an exam and cleaning every 6 months, a hygienist visit ASAP due to plaque and calculus buildup, a periodic oral exam, and adult prophylaxis, but the record did not show these follow-up appointments were completed. The Scheduler stated they did not receive an order to schedule follow-up dental appointments after the annual exam, and the facility policy stated social service staff would assist residents in securing routine or emergency dental care.
Failure to Prevent Verbal and Physical Abuse
Penalty
Summary
The facility failed to prevent verbal abuse involving a resident and a nurse. The resident, who had an intact cognition and a diagnosis of Chronic Obstructive Pulmonary Disorder, reported that after requesting pain medication and cough syrup, there was a significant delay in receiving the medication. When the nurse finally responded, an argument ensued during which both the resident and the nurse exchanged derogatory language. The nurse admitted to using curse words, stating that she felt threatened and was attempting to protect herself, rather than to escalate the situation. Additionally, the facility did not prevent resident-to-resident physical abuse between two residents with impaired cognition. One resident was found with a bleeding lip and redness under the eye, and staff determined that the injuries were likely caused by the roommate, who was observed attempting to pull the injured resident out of bed. Both residents required staff assistance with mobility and transfers, and neither could articulate what had happened due to their cognitive impairments. Staff responded by separating the residents after the incident. The facility's policies require that residents be protected from all forms of abuse, including verbal and physical abuse. However, in these instances, staff did not maintain professionalism or effectively deescalate the situation, resulting in both verbal and physical altercations involving residents and staff.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, potentially affecting all 132 residents. A review of the CMS Payroll Based Journal Staffing Data Report for the 1st quarter of 2025 indicated excessively low weekend staffing. The Daily Staffing Sheets for the same period revealed multiple dates without RN coverage, specifically on 10/15/25, 10/16/25, 10/25/25, 11/6/24, 11/13/24, 11/14/24, 11/18/24, 11/19/24, 11/20/24, 12/7/24, and 12/24/24. During an interview, the Staff Scheduler explained the difficulty in hiring and retaining RNs and noted that call-ins occur frequently. The Director of Nursing stated that the expectation is to have adequate RN coverage. The facility's Staffing and Scheduling policy emphasizes staffing according to resident acuity and needs, which was not met as evidenced by the lack of RN coverage on the specified dates.
Failure to Provide Required CNA In-Service Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three CNAs. CNA E, hired on March 1, 2022, CNA F, hired on March 16, 2022, and CNA G, hired on March 14, 2017, did not receive the mandated training. During interviews, Staff Developer B, who is new to the position, acknowledged being trained differently regarding the timing and method of fulfilling the CNAs' annual training requirements. The Director of Nursing (DON) expressed the expectation that CNAs should meet their required training hours. The facility's assessment indicated that in-service training must be sufficient to ensure the continuing competence of nurse aides, with a minimum of 12 hours per year.
Failure to Maintain Sanitary Conditions for Tube Feeding Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for residents receiving tube feeding, as observed in three residents. On multiple occasions, the tube feeding poles and floors next to the beds of these residents were found with large amounts of dried formula. This unsanitary condition persisted over several days, indicating a lack of proper cleaning and maintenance. The residents involved had severe cognitive impairments and were dependent on staff for activities of daily living, making them particularly vulnerable to the effects of such deficiencies. The Director of Nursing acknowledged that the expectation was for nurses to clean spills and for housekeeping to address the issue when necessary. However, the facility's policy on daily cleaning procedures, which includes disinfecting high-touch items and damp mopping floors, was not adhered to in these cases. The failure to follow these procedures resulted in the unsanitary conditions observed, as the tube feeding poles and surrounding areas were not properly cleaned, compromising the cleanliness and safety of the residents' environment.
Failure to Update Care Plans for Resident Safety
Penalty
Summary
The facility failed to timely revise care plans to accurately reflect identified problems and interventions for a resident. On multiple occasions, the resident was observed in situations that indicated a lack of appropriate care and supervision. The resident was found halfway off the bed and on the floor, wearing a wet brief that was hanging off. The resident appeared confused and unsure about what to do when asked about their care. On subsequent days, the resident was observed without a brief, non-slip socks, and walking barefoot, indicating a lack of attention to their personal care and safety needs. The resident's medical record revealed a history of multiple diagnoses, including Acute Respiratory Failure, Dementia, Anxiety, and Macular Degeneration. Despite a recent fall, the care plan for falls had not been updated since September of the previous year, lacking substantial recent interventions. The Director of Nursing confirmed that the expectation is for care plans to be updated after a team review of any falls. The facility's policy requires comprehensive care plans to be patient-centered and consistent with the resident's rights, reflecting current standards of practice, which was not adhered to in this case.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who has medical diagnoses of epilepsy and dysphagia, was observed struggling to drink from a foam cup and reported that they usually use a smaller sippy cup, which had broken two months prior. Despite a physician's order for a modified lightweight water cup and a directive to ensure the resident had a smaller drinking cup at their bedside, the resident was observed without the necessary adaptive equipment. Interviews with facility staff revealed a lack of follow-through in providing the required adaptive equipment. The Registered Dietitian mentioned that the Occupational Therapist had suggested the resident could use a regular foam cup, and the Director of Nursing acknowledged the previous use of a sippy cup but indicated a need to reorder one. The facility's policy on adaptive eating equipment emphasizes the importance of providing such equipment based on comprehensive assessments to help residents achieve their highest functioning potential, which was not adhered to in this case.
Failure to Document and Complete Skin Treatments
Penalty
Summary
The facility failed to complete and document skin treatments for a resident, identified as R93, who was observed with an undated bandage on their right leg. The resident, who had been admitted with diagnoses including Cellulitis of the Right Lower Limb and Peripheral Vascular Disease, was cognitively intact and required limited assistance with daily activities. A physician's order dated January 8, 2025, specified daily wound care for the resident's right lower leg, including cleansing with wound cleaner, applying medihoney, and covering with abdominal pads and kerlex. A review of the Treatment Administration Record (TAR) for January, February, and March 2025 revealed multiple dates where the prescribed treatments were not documented as completed. The Director of Nursing confirmed that the expectation was for treatments to be completed as ordered. The facility's policy stated that residents admitted with skin impairments should have appropriate interventions implemented to promote healing, with a physician's order for treatment and a treatment record initiated.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with a history of severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who was admitted with encephalopathy, was observed multiple times lying on their backside without the necessary offloading interventions, such as pillows under their sides, despite being at high risk for skin breakdown. The resident's medical record indicated a recurrent open area on the sacrococcyx, which had progressed to an unstageable pressure ulcer with eschar and serous drainage. The care plan required repositioning every two hours with pillows, but observations showed this was not consistently implemented. Additionally, the Treatment Administration Record for March 2025 revealed that prescribed treatments for the resident's pressure ulcer were not documented as completed on several occasions. The Director of Nursing confirmed that the resident should have been repositioned every two hours, highlighting a failure to adhere to the care plan and facility policy aimed at preventing facility-acquired pressure ulcers. This deficiency in care was identified through observation, interview, and record review, indicating a lapse in the facility's pressure ulcer prevention and management protocols.
Failure to Apply Prescribed Splint for Resident with Limited Mobility
Penalty
Summary
The facility failed to apply a splint/brace for a resident with limited mobility, as observed during a survey. The resident, who was admitted with medical diagnoses of dysphagia and cerebral infarction, was seen on two separate occasions without the prescribed bilateral elbow/hand splint in place. Instead, a towel was rolled up in the resident's left hand. The resident's medical records indicated an active physician order for the splint, but it was not applied as required. Interviews with facility staff revealed a lack of clarity regarding the responsibility for applying the splint. The Director of Nursing was unable to provide information on the application schedule for the splint, and the Restorative Nurse stated that the nursing staff was responsible for applying the splints, although the facility policy indicated that either restorative staff or a licensed nurse should handle this task. Despite requests, no application schedule for the splint was provided by the end of the survey.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a preferred and palatable temperature for three residents. Resident 20 expressed dissatisfaction with the meals, stating that the vegetables served were cold and hard, leading their daughter to purchase food from outside. This resident was cognitively intact, as indicated by a BIMS score of 15, and had multiple diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. Resident 31 reported that all meals at the facility were not good, while Resident 94 mentioned that the food did not look good and that they were not given enough food when it was good. The resident council meeting minutes from February 2025 revealed multiple complaints about the food, specifically noting that food was cold upon arrival and that food carts were left on the units for extended periods. The facility's policy on food palatability and hot food temperatures, dated 2018, stated that hot foods should be held at or above 135°F and acknowledged that food temperatures would drop by the time they reached the residents. However, the facility did not adequately address the variance in food temperatures, leading to dissatisfaction among residents.
Failure to Obtain Immunization Consents
Penalty
Summary
The facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents, leading to a deficiency. For one resident, identified as R34, the Infection Control Preventionist (ICP) was aware that the responsible party had refused all vaccinations, but the documentation of these refusals could not be located. The resident had medical diagnoses of Dysphagia and Cerebral Infarction and required staff assistance with bed mobility and transfers. The resident's mental status assessment indicated they were unable to complete the assessment, further complicating the consent process. For another resident, identified as R92, the facility provided a consent sheet that lacked signatures and had a note indicating a disconnected phone line. The resident had medical diagnoses of Cerebral Infarction and Sepsis, with an impaired cognition score and required staff assistance with bed mobility and transfers. The ICP acknowledged that the phone line was disconnected when attempting to obtain consent from the responsible party, but there was no follow-up action documented. The facility's policy required offering pneumococcal and annual influenza vaccines, but the lack of proper documentation and follow-up led to the deficiency.
Failure to Document COVID-19 Vaccination Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declination for the COVID-19 immunization for two residents, R34 and R92, as identified during a survey. For R34, the Infection Control Preventionist (ICP) was aware that the responsible party refused all vaccinations, but the documentation of this refusal was not found. R34 was admitted with medical diagnoses of Dysphagia and Cerebral Infarction and had a Brief Interview for Mental Status score indicating they were unable to complete the assessment. R34 required staff assistance with bed mobility and transfers, yet no consent or declination documentation was provided by the end of the survey. For R92, the documentation provided lacked signatures and included a note about a disconnected phone line. R92 was admitted with diagnoses of Cerebral Infarction and Sepsis and had an impaired cognition score. The ICP mentioned that the phone line was disconnected when attempting to obtain consent from the responsible party, but there was no follow-up on this issue. The facility's policy required maintaining documentation for all residents and staff on COVID-19 vaccination, which was not adhered to in these cases.
Failure to Assist Resident with Financial Management
Penalty
Summary
The facility failed to ensure a resident's right to manage their finances and assist with community banking services, leading to a deficiency in resident rights. A resident, who was cognitively intact, expressed concerns about being harassed by the facility regarding bill payments and receiving an involuntary discharge notice. The resident had difficulty accessing funds due to an expired driver's license, which limited their ability to withdraw sufficient cash from the bank. Despite having the funds, the resident was unable to pay the full amount due to these banking limitations. The Business Office Manager (BOM) acknowledged the resident's use of a credit card for bill payments and noted that the resident began not paying the bill in full. Although the BOM assisted the resident in visiting a local bank, the expired driver's license prevented further transactions. The facility did not assist the resident in renewing the driver's license, which contributed to the financial management issue. The facility's policy states that residents have the right to manage their financial affairs, but the resident was pressured to fill out an ACH form under the threat of involuntary discharge.
Failure to Permit Readmission and Provide Proper Discharge Notice
Penalty
Summary
The facility failed to permit the readmission of a resident following hospitalization, violating the requirement to provide proper notice of a facility-initiated discharge. The resident, who had been living at the facility since March 2024, was hospitalized after exhibiting aggressive behavior, including hitting doors and using vulgar language towards staff. Despite being medically and behaviorally cleared for return by the hospital, the facility refused readmission, citing an inability to accommodate the resident's needs due to their aggressive behavior. The facility did not complete the necessary involuntary discharge notice, nor did they communicate adequately with the resident's guardian or the ombudsman about the decision not to readmit the resident. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, revealed that the decision not to readmit the resident was based on the perceived danger the resident posed to themselves and others. However, the facility did not document any communication with the hospital regarding the resident's behavior at the time of discharge, nor did they follow the proper procedures for a facility-initiated discharge. The resident's legal guardian and the ombudsman were not informed of the specific behaviors that led to the decision, and the facility did not provide the required notice for discharge, resulting in a deficiency citation.
Failure to Provide Timely Fresh Water to Residents
Penalty
Summary
The facility failed to provide fresh water in a timely manner for several residents, as observed during a survey. On the morning of October 9, 2024, multiple residents were found with water cups that were dated from the previous night, indicating that they had not received fresh water since then. Resident R701 had an empty and warm water cup, and by midday, the same cup was still present without being refilled. R701 expressed that they never receive fresh water and that it is an ongoing issue. Similarly, R702's water cup was half full and warm, and they expressed a desire for fresh water, stating they would ask a CNA when they came into the room. R703 and R705 also had similar experiences, with warm water cups that had not been refreshed, and both residents expressed dissatisfaction with the lack of fresh water. The facility's policy on hydration states that fresh bedside drinking water should be available at all times unless contraindicated, and residents should be assisted to drink throughout the day. However, the observations and resident statements indicate that this policy was not being followed. CNA B mentioned that the water cart is usually cleaned and returned to the floor by 8:00 AM, and they try to pass water by lunchtime or earlier. Despite this, the Director of Nursing (DON) was unaware of any issues with residents receiving fresh water, suggesting a communication gap between staff and management regarding hydration needs.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain dignity and respect for a resident, identified as R704, who reported being verbally abused by a Certified Nursing Assistant (CNA C). During an interview, R704 recounted an incident where CNA C referred to their buttocks in a derogatory manner and mentioned that this was not the first occurrence of inappropriate behavior by CNA C. R704 had previously communicated these issues to the Unit Manager and the Wound Care Nurse (WC Nurse), expressing feelings of being dehumanized and requesting a transfer to another facility. The WC Nurse confirmed that R704 had reported CNA C's refusal to provide care and derogatory comments a couple of months prior, and stated that the behavior was reported to the Nursing Home Administrator (NHA). The Director of Nursing (DON) and NHA were made aware of the incident on the day it occurred, and CNA C was suspended and subsequently terminated following an investigation. R704, who was admitted with multiple fractures of the pelvis and required assistance with daily activities, was found to be alert and oriented, and had clearly articulated their needs and concerns about the verbal abuse and neglect they experienced.
Deficiency in Call Light Accessibility and Response
Penalty
Summary
The facility failed to ensure that call lights were functioning and within reach for two residents, leading to a deficiency. One resident, identified as R702, was observed without a call light cord, making it impossible for them to activate the call light. The resident, who has impaired cognition and requires assistance with activities of daily living, was unaware of how long they had been without a call light. A Certified Nursing Assistant (CNA) was unaware of the missing call light button until it was pointed out and subsequently replaced the cord, intending to notify maintenance. However, the call light was later found tucked under the resident's pillow, out of reach from their wheelchair. Another resident, R704, was observed with an activated call light that went unanswered for an extended period. Despite the resident's intact cognition and need for assistance with bed mobility and transfers, their call light remained on for over 20 minutes before an unknown staff member turned it off and informed a CNA of the resident's need for care. The Director of Nursing (DON) stated that call lights should be within reach and answered within 15 to 20 minutes, but was unsure if rounds were completed that morning to ensure compliance. The facility's policy emphasizes prompt response to call lights, which was not adhered to in these instances.
Sanitation Deficiency Due to Improper Linen and Trash Handling
Penalty
Summary
The facility failed to maintain a sanitary environment, potentially affecting all 129 residents. Observations made on multiple occasions throughout the day revealed various instances of dirty linen and trash being improperly stored or left unattended in resident rooms and common areas. Specific findings included a wheelchair with dirty clothing in the hallway, bags of dirty linen on floors and counters, and trash bags left in bathrooms, all contributing to a strong foul odor in some areas. These observations were consistent across different times, indicating a persistent issue with the handling and removal of soiled materials. Interviews with staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed discrepancies in the understanding and execution of responsibilities regarding the removal of dirty linen and trash. The CNA indicated that CNAs are responsible for removing linen and trash containing incontinence products, while housekeeping handles other trash. However, both the ADON and DON stated that CNAs should remove both linen and trash after providing care. The facility's policy on housekeeping and laundry emphasized the importance of regular collection and removal of soiled linen to prevent odor and infection control issues, but the observed practices did not align with these guidelines.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident diagnosed with Juvenile Rheumatoid Polyarthritis, who was dependent on staff for activities of daily living (ADL). The resident, who had intact cognition, was observed with a sign above their bed indicating a shower schedule of Monday and Thursday between 7 PM and 7 AM. However, the resident reported not receiving showers as scheduled and could not recall the last time they had one, suggesting it was in August. Documentation revealed that showers were marked as not applicable (N/A) on several dates in August and September. The Director of Nursing (DON) acknowledged that the resident had raised concerns about the timing of their showers, leading to a change from an afternoon to a day shift schedule. However, the staff member responsible for the resident's care continued to mark showers as N/A, mistakenly believing the resident was still on the afternoon schedule. The DON confirmed that the resident did not receive showers on the days marked N/A and explained that the staff should have verified the schedule change with a manager or the DON. The facility's policy on tub baths or showers did not address the specific concern raised in this incident.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident, identified as R902, who was admitted with diagnoses including idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with diabetic neuropathy. The resident reported experiencing pain due to long toenails, which made it difficult to wear shoes. Despite being admitted in October 2023, the resident was not seen by podiatry until August 2024, with a possible visit in April 2024 that could not be confirmed due to the absence of a treatment record. The facility's social worker confirmed that the resident was due for another podiatry visit in June 2024, which did not occur. The facility lacked a written policy and procedure for podiatry care, as confirmed by the social worker. The resident's electronic medical record showed a request for podiatry services in February 2024, a nursing note in July 2024 indicating the family's concern about the resident's toenails, and a physician order for podiatry services in March 2024. A second request for podiatry services was made in July 2024, and a podiatry visit finally occurred in August 2024. The facility's foot care policy emphasized the importance of regular foot inspections and documentation, particularly for diabetic residents, but these procedures were not adequately followed for R902.
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What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harper Woods
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Grosse Pointe | 1.4 mi | ★★★★★ | 1 | 0 |
| The Rivers Health & Rehabilitation Center Of Gross | 1.6 mi | ★★★★★ | 9 | 0 |
| Riverview Health And Rehab Center North | 1.7 mi | ★★★★★ | 1 | 0 |
| Regency At St. Clair Shores | 2.1 mi | ★★★★★ | 0 | 0 |
| The Orchards At Roseville | 3.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.