Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Redford during CMS and state inspections, most recent first.
Failure to submit PBJ staffing data: The facility did not electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable data. Review of the PBJ report showed the quarterly staffing data was not submitted, and the facility triggered a one-star staffing rating for lack of reported or inadequate staffing. The HR Director stated the omission was due to a clerical error, but no further explanation was provided.
Water Management Program Not Active for Inactive Fixtures: The facility failed to maintain an active and ongoing plan to reduce the risk of legionella and other OPPP by flushing inactive fixtures and managing unused plumbing. An unused shower room was locked and, when accessed, released brown, rusty water from the shower pipe. A locked room containing an unused wheelchair washer was also found, and staff were unsure whether its water supply had been shut off. The IP stated they were not part of the Water Management Team, despite the program listing the IP as a member.
Surveyors found that mechanical ventilation in a soiled utility room and in resident bathrooms on two halls was not functioning. A strong, pungent odor was present in the soiled utility room, and testing of the ceiling vents with tissue paper showed no suction. The maintenance supervisor confirmed the vents were non-functional and reported that a single unit controlled ventilation for the soiled utility room and both halls’ bathrooms, suggesting a possible belt issue. This failure had the potential to affect all residents on those halls.
A resident with COPD, OSA, and HTN, cognitively intact per BIMS, reported that their call light had not worked since returning from the hospital and that on multiple nights they were unable to summon staff for needed toileting assistance, resulting in incontinence episodes. Observation showed the call light button lying on the bed with the call system box detached from the wall, and no alternate means for the resident to contact staff. An LPN stated that call lights should alert staff pagers and display on an office screen, but when the LPN tested this resident’s call light, no pager alert or audible signal occurred, even though the room number appeared on the office monitor. The LPN confirmed the call light for this resident was not functioning and could not explain the cause.
A resident complained that the wall-mounted AC filter in her room was never cleaned and said she was breathing in dust while on oxygen and already having difficulty breathing. The unit was observed running and blowing air toward the foot of her bed, with the exterior coated in dust and the interior filter visibly soiled. The Maintenance Supervisor confirmed the dusty unit and said housekeeping cleaned the exterior while maintenance cleaned the filter.
A resident with MS, paralysis, and an unstageable left hip pressure ulcer did not receive timely showering or brief changes. The resident reported not having had a shower for weeks, said staff told them they were not signed up for one, and remained wet or soiled for extended periods despite repeated call light use and requests for help. A CNA said the resident could not shower because of a wound, and an LPN later observed the resident was wet and needed a brief change.
A facility failed to provide enough nursing staff to meet resident needs and ensure a licensed nurse was in charge on each shift. An alert resident reported call lights on the night shift could take up to an hour to be answered, another resident returning from dialysis was left with a cold meal tray that nursing staff did not reheat, and a guardian said daily visits were needed because the unit was frequently short-staffed. Staff interviews described CNA shortages, high turnover, and difficulty completing assigned care tasks.
Failure to provide timely dental services for a resident with dementia and DM who needed supervision for oral care. The resident reported recent mouth concerns, including sore gums and possible infection, and records showed fractured and missing teeth, tooth decay, and a tooth partly coming off. An NP documented that a dentist evaluation was needed, but there was no documentation the resident was seen by dental services during the relevant monthly visits, and the ordered Orajel was not documented as given.
A facility failed to provide coffee for two residents who requested it and preferred it with meals and at other times. During breakfast observation, coffee was available on a side table but was not offered or given to residents, even though the menu called for beverages of choice and the RD, DS, and CDM stated coffee was sent to the units daily and nursing staff was responsible for serving it. One resident reported missing morning coffee and said staff often told them it was unavailable outside breakfast, while another resident with DM, HF, and lung disease reported the facility removed a hotpot used to heat water for coffee and that staff told them no coffee was available.
Multiple dependent residents were not provided timely assistance with ADLs, positioning, and toileting, and did not have reliable access to a functional call system. One resident with severe contractures and multiple pressure-related wounds was left in the same twisted position for extended periods without appropriate offloading devices or a specialty mattress, and with the call light out of reach. Another resident with cognitive impairment and chronic conditions remained in bed in a poor position, unable to reach the call light or effectively use the bed controls. A resident with stroke and heart failure reported nonfunctioning call lights and was later observed slid down in a wheelchair and unable to reposition or lock brakes without help. Additional residents reported delays in being changed when wet, missed showers, and difficulty obtaining assistance after incontinence, while their call lights were placed across the room or did not reliably signal staff. Staff acknowledged that the call light system had not produced an audible alert for months, with calls only visible on a monitor inside the nurse’s office and no door lights or chimes, contrary to the facility’s own policy on answering call lights promptly.
Surveyors found that multiple residents had nonfunctional or inaccessible call lights, with devices placed out of reach, hidden under bedding, or looped over wall boxes across the room. Some residents reported that their call lights did not work and were given hotel-style desk bells that did not reliably ring or summon staff. Testing showed that call light activations appeared visually on the nurse office monitor but did not trigger any audible alarm or corridor door light, including one call that had been active for an extended period. An LPN stated the call lights had not been audible for months and that the system had not worked properly for more than six months, while the facility’s policy addressed answering call lights promptly but did not address maintaining call light functionality.
Surveyors found that the facility failed to implement and maintain effective fall-prevention interventions and environmental safety measures for two residents with significant cognitive and physical impairments. One resident, who was totally dependent for bed mobility and had severe contractures and pressure wounds, had an actual fall from bed but was repeatedly observed without the care-planned concave or specialty mattress, without supportive pillows, with an unsecured catheter leg anchor, and with an inaccessible call light on a unit where staff reported the call system had not worked properly for months. Another resident, identified in the care plan as at risk for falls due to weakness, poor safety awareness, and impulsivity, experienced multiple falls resulting in head injuries and later a hip fracture, yet no new or revised fall-prevention interventions were documented between the initial and subsequent falls, and staff described relying mainly on monitoring and keeping the resident in common areas despite ongoing impulsive behavior.
A resident with anxiety disorder and chronic kidney disease activated their call light, which remained unanswered for over an hour and a half. The call light system did not illuminate over the door and was only visible on a screen at the nurses' station, which staff reported as unreliable. Staff interviews confirmed reliance on this system, and resident council notes documented ongoing concerns about delayed call light responses.
The facility failed to provide a dignified dining experience for several residents, with some waiting to be served while others ate, and others not receiving necessary assistance or appropriate meal items. Observations included residents watching others eat without being served, a resident with a wet shirt and no clothing protector, and a CNA explaining delays within hearing range of residents. The facility's policy on dignity was not upheld in these instances.
The facility failed to provide two residents with alternate meal options and desserts during scheduled meals. One resident, a vegetarian, was served a meal without dessert, and another resident did not consume their meal due to dislike, with only a bacon sandwich offered as an alternative. The facility's menu guidelines were not followed, affecting the nutritional needs of all 78 residents.
The facility failed to provide post-dinner snacks to 18 residents in the [NAME] Houses. Observations and interviews revealed that the kitchen did not send snacks, and the [NAME] House Manager reported no contract existed for snack provision. Limited food items were found in the kitchen, and staff often used personal funds to buy snacks. The Certified Dietary Manager stated snacks were not her responsibility, indicating a lack of communication and responsibility.
The facility failed to ensure proper sanitization of dishware in the [NAME] House, as the dish machine lacked a connected sanitizer and staff used incorrect test strips. This deficiency had the potential to cause foodborne illness among residents.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices, as staff did not wear necessary protective equipment and there was no signage indicating EBP requirements. Additionally, a linen cart was improperly used to store personal items and had a stained, damaged cover, which was not addressed promptly despite being reported.
The facility failed to maintain a functioning resident call system for four residents, with issues such as tied or detached cords and dead batteries rendering the systems unusable. The Maintenance Director was unaware of these issues until shown, highlighting a lapse in communication and maintenance reporting.
A resident with an indwelling urinary catheter developed a UTI due to the facility's failure to provide appropriate catheter care, assessment, and monitoring. The resident's clinical record lacked orders or documentation for catheter care, despite the presence of dark, cloudy urine with sediment. The facility's policy required routine catheter care to prevent infections, but it did not include documentation of the care provided.
A resident experienced significant weight loss due to inadequate nutrition and monitoring at the facility. The resident, a vegetarian, was served meals lacking in protein and variety, and was not provided with dessert on one occasion. Despite recommendations for weekly weight monitoring, the facility failed to conduct regular weight checks and re-weights, violating their own policies. The dietary manager acknowledged the meals were not nutritious and that protein replacements should have been offered.
A resident with a history of acute respiratory failure and a feeding tube was observed receiving tube feeding at an incorrect rate. The pump was set to deliver 70 mL per hour, contrary to the physician's order of 75 mL per hour. The error was confirmed by the Certified Dietary Manager, highlighting a failure to adhere to the facility's enteral nutrition guidelines.
A facility failed to provide a legally authorized representative for an incapacitated resident with cerebral palsy and polyneuropathy, who was unable to make informed healthcare decisions. Despite being deemed incapacitated, the resident had no healthcare power of attorney or legal guardianship in place, and the Social Services department had not secured a legal representative. The resident's niece was making healthcare decisions without legal documentation, and the facility did not provide evidence of securing representation by the survey's end.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data. During review of the PBJ report for the FY 2026 1st quarter, the facility was found to have not submitted the mandatory staffing data for the period of July 1, 2025 through September 30, 2025, and it also triggered a one-star staffing rating indicating a lack of reported staffing or inadequate staffing. In an interview, the Staffing Scheduler and HR Director stated that the quarterly staffing numbers were not submitted to CMS because of a clerical error, and no further explanation was provided regarding the specific error.
Water Management Program Not Active for Inactive Fixtures
Penalty
Summary
The facility failed to have an active and ongoing infection prevention and control plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, including flushing all inactive fixtures to eliminate stagnation. During observation on 4/8/26 at 10:00 AM, the shower room on the [NAME] Hall was found posted as not in use and locked. Maintenance Supervisor I stated he would need to find a key, then drilled through the lock to access the room. He stated the water to the unused shower room had been shut off. When the shower knob was turned, a rush of brown, rusty water shot out of the pipe. Later that morning, room [ROOM NUMBER] on the [NAME] Unit was observed to be locked, and Maintenance Supervisor I stated he was unsure what the room was used for. After unlocking the door, a large wheelchair washing unit was found inside. Maintenance Supervisor I stated he was unsure whether the water supply to the wheelchair washer had been turned off, and when the machine was turned on, water began to fill the unit. Nurse Manager E stated that the facility does not use the wheelchair washer located in that room. The Infection Preventionist stated they were not part of the facility's Water Management Team, despite the facility's undated Water Management Program listing the Infection Preventionist as a team member.
Failure to Maintain Functional Mechanical Ventilation in Soiled Utility Room and Resident Bathrooms
Penalty
Summary
The facility failed to maintain functional mechanical ventilation for the [NAME] and North halls and the [NAME] soiled utility room. During observation with Maintenance Supervisor I, the soiled utility room was noted to have a strong, pungent odor. The mechanical ventilation in this room was tested by placing a piece of toilet tissue against the ceiling vent grate, and no suction was present, as the tissue did not cling to the grate cover. Maintenance Supervisor I confirmed that the vent was not functional. Mechanical ventilation in the resident bathrooms on the [NAME] and North halls was checked in the same manner and was also found to be non-functional. Maintenance Supervisor I confirmed that the same unit controlled ventilation for the soiled utility room and the [NAME] and North Hall bathrooms and stated that there might be an issue with the belt. This failure to maintain the mechanical ventilation system had the potential to affect all residents on the [NAME] and North halls.
Failure to Maintain Functional Call Light System for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a properly functioning call/communication system for a resident’s room and bathroom/bathing area. The resident reported that since returning from the hospital two weeks prior, their call button had not worked. They stated that on the past two nights they needed assistance to use the restroom, depended on staff for toileting, and when they pressed the call bell no one responded; by the time staff arrived, the resident had already had a bowel movement on themselves. During observation of the room, the call light button was found on the resident’s bed and the call light box was detached from the wall. The resident had no bell or any other means to communicate with staff when assistance was needed and reported feeling uneasy at times due to being unable to contact staff. Record review showed the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Essential Hypertension, and had a BIMS score of 15, indicating no cognitive impairment. An LPN reported that the call lights were supposed to send alerts to staff pagers and display on a screen in the office. When asked to demonstrate the system in this resident’s room, the LPN pressed the call button and confirmed that no alert went to their pager; although the room number appeared on the office screen, there was no sound or pager alert to notify staff that assistance was needed. The LPN acknowledged that the call light was not working for this resident and was unsure why it was not functioning. The facility’s call light/response time policy was requested but was not provided prior to survey exit.
Dusty Air Conditioning Unit in Resident Room
Penalty
Summary
The facility failed to maintain the wall-mounted air conditioning unit and filter in a clean manner in Resident #40’s room. On 4/8/26 at 2:30 PM, Resident #40 complained that the filter for the unit was never cleaned and stated she was breathing in dust; she was visibly upset and reported that she was on oxygen and already had a hard time breathing. The air conditioning unit was observed running and blowing air directly at the foot of her bed, and the outside front cover was coated with dust while the interior filter had a buildup of dust. At 2:40 PM, the Maintenance Supervisor stated housekeeping was responsible for cleaning the exterior of the unit and maintenance was responsible for cleaning the filter, and confirmed the unit was dusty.
Delayed Showering and Incontinence Care
Penalty
Summary
The facility failed to ensure timely showers and incontinence care for a dependent resident with Multiple Sclerosis, paralysis, and an unstageable pressure ulcer of the left hip. On 04/07/2026, the resident was observed lying in bed in a hospital-style gown and reported not having received a shower the prior day despite asking staff, and also stated they had not had a shower in the three weeks they had been at the facility. The resident reported needing assistance to shower because of MS and said their brief was wet. When the resident activated the call light and a CNA entered, the resident asked about getting a shower, and the CNA stated the resident could not shower because they had a wound. The CNA also stated the resident’s showers were scheduled for Monday and Thursday, but a shower was not offered at that time. The resident continued to report delayed incontinence care throughout the day. After activating the call light, the dome light above the door did not activate and there was no audible hallway tone. A staff member entered and exited the room without changing the resident’s brief, and later the resident reported still being wet with urine after asking to be changed. The lunch tray was set up while the resident remained wet, and later the resident again reported being soiled and said staff had not returned. On 04/09/2026, the resident again reported being wet and soiled and said staff had told them they could not be changed because breakfast was being served. An LPN later observed the resident was wet and in need of a brief change and stated timely changing was important because of the resident’s hip wound. Records showed the resident required substantial to maximal staff assistance for toileting hygiene, rolling in bed, and lower body dressing, and the care plan directed staff to check the resident at least every two hours during the day, change the brief if needed, and keep the resident clean and dry.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift, as shown by observations, interviews, and record review involving three residents. One alert and cognitively intact resident reported that during the night shift, call lights sometimes took as long as an hour to be answered and stated that being left waiting to be changed for an hour was unacceptable. Another alert and cognitively intact resident who received dialysis three times a week and was identified as a nutritional risk and underweight reported that when returning from dialysis, a meal tray was left at the bedside and no staff were available to reheat the food; the resident stated this had been happening for a while and that cold food was left after dialysis. The registered dietitian stated the resident’s food should have been reheated by nursing staff. A third resident’s legal guardian stated daily visits were needed to ensure the resident was fed and cared for because the unit was frequently short-staffed. The staffing scheduler, who was also a CNA, reported shortages especially on the afternoon and midnight shifts, high turnover, and that the facility often had to pull staff when there was a call-in. CNAs reported the unit was often staffed with only two or three people despite residents needing two-person assistance for lifts, and that they were expected to pass trays, assist with meals, clean trays, do resident laundry, and provide showers, making it difficult to complete assigned tasks within an eight-hour shift. The DON and Administrator stated staffing was arranged with one nurse on the Transition Care unit, two on the [NAME] unit, and one nurse for the Greenhouse, where less complex residents were placed.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for one resident with dementia and diabetes who required assistance with personal hygiene and oral care. The resident reported not having been seen by a dentist recently and described a concern for a mouth infection with redness to the lower gumline. The most recent dental note documented two fractured teeth and seven missing teeth, and a nurse practitioner later documented tooth decay, a tooth that had partly come off, and pain to the upper gumline, with an assessment noting dental caries/sore gums and that a dentist evaluation was needed. Facility records showed the resident was admitted in March 2024 and had an active care plan stating supervision was required for personal hygiene and oral care. A dental services order was entered in February 2026, and the unit manager reported the dental service was on site monthly to follow up on referrals, but no documentation was provided showing the resident was seen by dental services in February or March 2026. The ordered Orajel was also not documented as given, and the DON stated the facility did not keep Orajel on hand and it needed to be ordered.
Failure to Provide Requested Coffee and Beverage Preferences
Penalty
Summary
The facility failed to provide coffee for two residents who had expressed a preference for it during breakfast and at other times of the day. On 4/7/2026, one resident was heard asking the UM for coffee and later stated, "I never get coffee, it makes me feel so good in the morning, I miss my coffee." On 4/8/2026 during breakfast observation, the same resident asked a CNA for coffee, and a nurse said she would get it; coffee was observed on a side table with other beverages, but residents were not offered or given coffee during the meal service. The master menu reviewed with the RD indicated residents were to be served juice/beverage of their choice and milk if desired, and the RD stated coffee was sent to the units daily but could not explain why nursing staff was not giving residents coffee. The DS and regional CDM stated coffee was sent to both units daily for breakfast and nursing staff was responsible for providing residents with the beverage of their choice. A second resident reported the facility had taken away their hotpot appliance that heated water for coffee and said they missed having it because they might get coffee in the morning but were unable to get it at other times during the day. The resident stated staff had told them no coffee was available when requested, and no coffee cup was observed in the room during observations. The DON reported the hotpot had been removed about a year earlier because it was a heat source that may cause a fire. Activity staff reported coffee was available on most days on the resident's unit, but also stated the resident did not come out for coffee hour and was not aware of other times. The resident, who was admitted on 02/14/23 and had diagnoses including diabetes, heart failure, and lung disease, was documented as dependent on staff for meeting emotional, intellectual, physical, and social needs and needing set-up assistance to eat.
Failure to Provide Timely ADL Assistance and Maintain Functional Call Light Access
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), positioning, and access to call systems for multiple dependent residents. One resident with multiple sclerosis, lower leg contractures, malnutrition, and documented dependence on staff for all hygiene, toileting, dressing, bed mobility, and transfers was repeatedly observed lying in bed in the same position over extended periods on consecutive days. The resident’s legs were contracted with heels at the buttocks, knees pointed to one side, and the torso twisted, with visible gauze dressings on both feet and the right hip showing bloody drainage soaked through in several areas. No pillows or devices were in place to pad bony prominences or separate the legs and feet, and no specialty or low air loss mattress was in use despite care plan directions to reposition frequently and use a concave mattress. The call light was either under the covers or hanging over the headboard, out of the resident’s reach, while the responsible party reported multiple open pressure-related wounds on heels, sides of feet, hips, and buttocks. Another resident with Alzheimer’s disease, heart disease, chronic pain, and a care plan indicating dependence or supervision for ADLs and bed mobility was observed in bed with the head of the bed elevated but positioned so that their waist was beyond the bed’s break. The bed controller was hooked on the head of the bed and not readily usable, and the resident was unable to reach the call light placed at the shoulder or under the blankets. Over several observations in one day, the resident remained in bed with limited ability to adjust their own position and without clear access to the call system. A third resident with stroke, heart failure, dysphagia, and care plan needs for substantial assistance with bed mobility and dressing was observed pressing the call light multiple times without staff response during the interaction, reporting that the call lights were not working. Later, this resident was seen in a wheelchair in a hallway corner, slid down with buttocks at the edge of the chair and shoulders at the top of the low back, unable to lock both wheelchair brakes or reposition independently, and stating they needed help while nearby staff were occupied elsewhere. The same resident was later observed in bed with feet on the floor and the backs of the knees at the edge of the bed, still dependent on staff for ADLs. A resident with traumatic brain injury, epilepsy, anxiety, and a care plan indicating dependence on staff for most ADLs reported not being changed in a timely manner after waking early and requesting assistance, and also reported shoulder pain for which the facility did not consistently do anything. This resident’s call light cord was looped over the wall junction box, and a bell on the tray table did not ring reliably when tested, with no immediate staff response. Another resident with dementia and diabetes, dependent for toileting and needing substantial or partial assistance for other ADLs, was observed in bed without pants, with the call light looped over a wall box across the room from the bed and no secondary bell visible. The resident reported missed scheduled showers, difficulty getting staff to assist after incontinence episodes, and described being left in a wet brief that eventually soaked through to their pants before staff removed it. A urinal partially filled with urine was hanging inside a trash can, and the resident stated they did not always feel the need to void and had accidents. Across these residents, the call light system itself was found to be nonfunctional as an effective alert mechanism. Multiple residents reported or demonstrated that call lights did not work properly, and clocks in at least two rooms were not running. The LPN assigned to the unit stated that only one nurse was assigned to care for 17 to 24 patients and that the call light system had not worked properly for more than six months, with no audible tone and the monitor located inside the nurse’s office on top of a desk. During observation, activated call lights showed on the monitor, including one that had been on for 20 minutes, but there were no lights above the doors and no audible chime. The facility’s call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system. These conditions resulted in residents who were dependent on staff for ADLs, positioning, toileting, and safety being unable to reliably summon assistance or receive timely care.
Failure to Maintain Functional and Accessible Call Light System
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights were functional and accessible in multiple rooms and bathrooms, affecting at least six identified residents and additional rooms on the Transitional Care Unit. Surveyors observed several residents in bed over extended periods with call lights either out of reach, hidden under blankets, or looped over wall junction boxes across the room. One resident’s call light was repeatedly found under the covers or hanging over the headboard, while another resident reported their call light did not work and was instead provided a hotel-style desk bell that did not reliably ring or summon staff. Another resident’s call light was placed behind the head of the bed or at the shoulder where the resident could not reach it, and yet another resident pressed their call light multiple times without staff response. Additional residents had their call light cords looped over wall boxes far from the bed and were also given hotel-style bells, which did not consistently function when tested. Surveyors further noted that the central call monitoring station in the nurse office displayed activated room numbers but produced no audible chime, and corridor door lights did not illuminate when call lights were activated. During testing with the Maintenance Director, all tested call lights registered visually on the nurse office monitor but none triggered an audible sound, including one room that had been activated for 20 minutes. An LPN reported that the call lights had not been audible for months, that only one nurse was assigned to care for 17 to 24 patients on the unit, and that the call light system had not worked properly for more than six months. The facility’s written call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system itself. The administrator reported being unaware of the call light problem.
Failure to Implement and Maintain Effective Fall-Prevention Measures for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain effective fall-prevention interventions and environmental safety measures for two residents with known fall risk and significant functional impairments. For one resident (R901), surveyors observed the individual lying in bed with severe muscle wasting, contracted lower extremities, and dependence on staff for all bed mobility and activities of daily living. The resident’s bed was positioned with one side against the wall, a floor mat on the opposite side, and a pillow placed under the bottom sheet on the right side that did not actually support the resident. The call light was found under the bedcovers on the wall side and later hanging over the headboard, not accessible to the resident. The urinary catheter leg anchor was not secured, and no low air loss or specialty mattress was in place despite a care plan intervention for a concave mattress with side bolsters that had been initiated and revised in January. The resident’s responsible party reported multiple pressure-related wounds and questioned how the resident, who had contracted legs and minimal ability to move, could have fallen from bed onto the floor. Record review for R901 showed an actual fall documented on 01/10/26, with a progress note stating the resident was found lying on the floor mat near the bedside during morning rounds. The care plan documented that the resident had an actual fall and included interventions such as frequent repositioning in bed and use of a concave mattress. The Minimum Data Set indicated impaired cognition and total dependence on staff for hygiene, toileting, dressing, rolling in bed, and transfers. Despite these documented needs and planned interventions, surveyors repeatedly observed the resident over two days without the ordered specialty or low air loss mattress, without pillows or bolsters supporting the torso, and with the call light not positioned within reach. Additionally, an LPN reported that the call light system on the resident’s unit had not worked properly for more than six months, with no audible tone heard upon activation. For the second resident (R903), the facility did not implement additional or modified fall-prevention interventions despite multiple falls and known cognitive and mobility issues. Progress notes documented that on 01/16/26 the resident was found sitting on the floor with knees bent, with a hematoma and laceration to the forehead and abrasions to the cheek. The resident was assisted back to a wheelchair and later sent to the ED for a CT scan at the granddaughter’s request. Staff interviews indicated that this resident was wheelchair-bound, unsteady, impulsive, often attempted to ambulate or transfer without assistance, and was non-compliant with directions. The DON and unit manager reported that the resident had severe cognitive deficits, wanted to be independent, was less directable, and had three falls in a short period, including one in the chapel and another in a common area, with staff suspecting a UTI during this time. R903’s care plan identified the resident as at risk for falls due to weakness, gait imbalance, poor safety awareness, impulsivity, and transferring without assistance, with interventions such as ensuring wheelchair wheels were locked, appropriate footwear, a safe environment, bed brakes locked, call light in reach, Dycem to the wheelchair, supervision so whereabouts were known, and a floor mat when in bed. However, no new or revised fall-prevention interventions were documented between the initial fall and subsequent falls on or before 01/19/26. The activity aide who witnessed one fall in the chapel reported the resident suddenly slid out of a chair and did not recall seeing non-slip material in the wheelchair seat. Staff also reported that after the initial fall, the facility’s practice was to keep residents in-house unless they were on blood thinners or had a mental status change, and the unit manager confirmed that the resident was kept in common areas after one fall but continued to be impulsive and experienced another fall from the wheelchair later the same day. The facility’s own fall management guidelines stated that the interdisciplinary team would review and modify the plan of care to minimize repeat falls, but documentation showed no additional interventions were added for this resident prior to the later fall with a hip fracture identified at the hospital.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
A deficiency was identified when a resident activated their call light at 12:11 PM, and it remained unanswered for over an hour and a half, with no staff responding until at least 1:43 PM. The resident reported that call lights are often not answered when activated, sometimes remaining on all night, and noted that the call light does not illuminate over the door but only appears on a screen at the desk, which was described as barely working. Observations confirmed that the call light was still activated at multiple intervals, and no staff entered the room to address the resident's needs during this period. Interviews with staff revealed reliance on a system at the nurses' station to monitor call lights, with staff indicating they check the system as long as it is functioning properly. The resident involved had diagnoses of General Anxiety Disorder and Chronic Kidney Disease and required assistance with bed mobility and transfers. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14/15. Review of resident council notes from the previous six months showed ongoing concerns about timely call light response, particularly during the midnight shift. Facility policy states that call lights should be answered promptly by available staff, but this expectation was not met in the observed incident.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during lunch meals on two separate occasions. On one occasion, three residents were seated together, but only two were served their meals promptly, leaving the third resident waiting and watching others eat. This resident was eventually served after the others had finished their meals. Additionally, another resident was observed with a wet shirt and no clothing protector, watching others eat without receiving assistance or a beverage until much later. When a beverage was finally provided, it included a straw, contrary to the resident's meal ticket instructions. Further observations revealed that two residents were left watching others eat without being served their meals, as they required assistance and had to wait for staff. A CNA explained this within hearing range of the residents, potentially causing embarrassment. The facility's policy on resident dignity and personal privacy emphasizes the importance of respecting and enhancing each resident's dignity and individuality, which was not upheld in these instances. The administrator acknowledged the issues and indicated a need for process refinement in the dining rooms.
Failure to Provide Alternate Meal Options and Desserts
Penalty
Summary
The facility failed to provide two residents, R44 and R69, with the option of an alternate entree, beverages, and preferred desserts during scheduled meals. On multiple occasions, R44 was observed without a meal or beverage while other residents were eating. When R44 was finally served a beverage, it contained a straw, contrary to their meal ticket instructions. Additionally, R44, a vegetarian, was served a meal that did not include the dessert on the menu, and the staff was unable to identify one of the pureed items served to them. On another occasion, R69 was observed not consuming their meal because they did not like the pot pie served. The only alternative offered was a bacon sandwich, which was the only available option in the greenhouse unit. R69 expressed a desire for dessert, which was not provided. The CNA reported that desserts were not supplied to the greenhouse residents, and there were no alternate menus or always available items for them. The facility's menu guidelines require that menus be planned in advance to meet residents' nutritional needs and include alternate meals and always available items. However, the facility did not adhere to these guidelines, as evidenced by the lack of alternate entrees and desserts for the residents. The deficiency in meal service has the potential to affect all 78 residents who rely on the kitchen for their meals.
Failure to Provide Post-Dinner Snacks to Residents
Penalty
Summary
The facility failed to ensure that post-dinner snacks were available and offered to 18 residents residing in the [NAME] Houses, out of a total census of 78. During observations and interviews, it was revealed that the Certified Nursing Assistant (CNA) and the [NAME] House Manager (GHM) reported that the kitchen did not send snacks to the houses. The GHM indicated that the kitchen staff did not have a contract with the [NAME] Houses to provide snacks, and they could not recall the last time snacks were provided. The facility's document titled HS (evening) snacks outlined that snacks and beverages should be provided as identified in individual care plans, but this was not being followed. Further observations of the [NAME] House kitchen revealed an empty snack basket and limited food items in the refrigerator, which were reserved for medication pass. The GHM stated that the residents were hungry, and staff often used their own money to buy snacks. A text message from the GHM to the Certified Dietary Manager (CDM) asking about snack provision went unanswered. When queried, the CDM stated that snacks were not her responsibility and referred the surveyor to the main kitchen, indicating a lack of communication and responsibility for ensuring residents received necessary snacks.
Improper Sanitization in Dish Machine
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, as observed during a survey. The deficiency was identified when the dish machine in the [NAME] House was found to be a low temperature, chemical sanitizing dish machine without a sanitizer attached. The [NAME] House Manager F was unable to explain how staff checked for sanitizer levels when no liquid sanitizer was connected to the dish machine. Additionally, the staff was using Smart Power test strips, which were not appropriate for the chemicals in use, indicating a lack of proper monitoring and understanding of the sanitization process. Further investigation revealed that the dish machine had only a bottle of liquid detergent and two bottles of liquid rinse aid connected, with no sanitizer present. When the [NAME] House Manager F attempted to rectify the situation by replacing the rinse aid with a bottle of liquid chlorine sanitizer, the chlorine test strip did not change color, indicating the absence of sanitizer. This failure to ensure proper sanitization of dishware had the potential to result in foodborne illness among all residents consuming food from the kitchen, as the facility did not adhere to the 2017 FDA Food Code requirements for chemical sanitization.
Failure to Implement EBP and Maintain Linen Sanitation
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices, including a urinary catheter, feeding tube, and tracheostomy. Observations revealed that staff did not wear isolation gowns or gloves when entering the resident's room or providing care, such as incontinence care and nebulizer treatment. Additionally, there was no signage indicating the need for EBP on the resident's door, and the facility's Director of Nursing confirmed that the resident should have been identified as requiring EBP. The facility also failed to store linens in a sanitary manner, as observed with a linen cart on the [NAME] Unit. The cart had a foam cup and a personal water bottle stored among clean linens, and the cover was stained and had holes. Staff acknowledged the inappropriate storage of personal items on the cart, and the Director of Nursing noted that the cart cover should be inspected for replacement. Despite being informed of the issue, the cover remained uncleaned and unreplaced by the following day.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to maintain a functioning resident call system in the bathrooms and bathing areas for four residents, leading to a deficiency in ensuring a safe environment. Observations revealed that the call system cords in the bathrooms of these residents were either tied to non-functional pieces, detached, or missing entirely, rendering them unusable for calling assistance. Specifically, one resident's bathroom had a pull-cord tied to a non-functioning piece of plastic, while another resident's shower pull-cord was detached from the alert system. Additionally, a resident's call light system was tested and found to be non-responsive, with no indication on the door or system monitor. The Maintenance Director (MD) was unaware of the issues until they were shown the non-functional systems. Upon inspection, the MD identified that some cords were improperly installed, and others had dead batteries, which contributed to the malfunctioning alert systems. The MD acknowledged the need for new cords and battery replacements to restore functionality. However, there was no prior communication to the MD regarding the need for repairs, indicating a lapse in reporting and addressing maintenance issues within the facility.
Failure in Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate urinary catheter care, assessment, and monitoring for a resident, resulting in the development of a urinary tract infection (UTI). The resident, who was observed with an indwelling urinary catheter, had dark, cloudy urine with sediment in the tubing. A review of the resident's clinical record showed no orders or documentation for catheter care, assessment, and monitoring, despite the resident's diagnoses, which included neuromuscular dysfunction of the bladder and a UTI. The resident's physician's orders included an antibiotic treatment for a UTI, but there was no documentation of routine catheter care as per the facility's policy. The Director of Nursing confirmed that an order should be written and documented by the assigned nurse. The facility's policy on indwelling catheter care emphasized the importance of routine care to prevent infections, but it did not include documentation of the care provided.
Inadequate Nutrition and Monitoring Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition and monitoring for a resident, identified as R44, who experienced significant weight loss. Observations revealed that R44, who is a vegetarian, was served meals lacking in protein and variety, such as pureed sweet potato and cabbage, and tomato soup with lima beans. Additionally, R44 was not provided with dessert on one occasion. Interviews with staff indicated a lack of knowledge about the nutritional content of the meals and the facility's policy on replacing protein for vegetarian residents. The facility's dietary manager acknowledged that the meals provided were not nutritious and that protein replacements should have been offered. R44's clinical records showed a history of weight loss, with weights dropping from 118.8 lbs in October 2024 to 93 lbs in March 2025. Despite recommendations for weekly weight monitoring, only two weights were recorded in a four-week period, and no re-weights were conducted when deviations occurred. The facility's policies on weight management and unintended weight change were not followed, as evidenced by the lack of regular weight monitoring and re-weights. The dietary manager was unable to explain the failure to adhere to these policies, highlighting a deficiency in the facility's nutritional care and monitoring processes.
Incorrect Tube Feeding Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's tube feeding formula was delivered at the physician-ordered rate. Observations on multiple occasions revealed that the pump was set to deliver the formula at 70 mL per hour, while the physician's order specified a rate of 75 mL per hour. This discrepancy was noted during observations on 3/31/25 and 4/1/25, where the pump's programmed rate did not match the rate indicated on the formula bottle and the physician's order. The resident involved had a medical history that included acute respiratory failure, stroke, aspiration pneumonia, and the presence of a tracheostomy and feeding tube. The Certified Dietary Manager confirmed the error upon reviewing the orders and acknowledged that the pump was incorrectly programmed. The facility's policy on enteral nutrition guidelines requires that the nurse administers the feeding regimen according to the physician's order, which was not adhered to in this case.
Failure to Provide Legal Representative for Incapacitated Resident
Penalty
Summary
The facility failed to ensure that an incapacitated resident, identified as R17, was provided with a legally authorized representative to make informed healthcare decisions. R17, who has diagnoses including Cerebral Palsy and Polyneuropathy, was observed to have difficulty communicating and was unable to answer questions. The resident's medical record indicated a BIMS score of 10, suggesting moderately impaired cognition, and a comprehensive care plan noted the need for assistance with all decision-making. Despite being deemed incapacitated by a physician and psychologist in July 2024, R17 did not have any healthcare power of attorney or legal guardianship documentation in place. The facility's Social Services department was responsible for obtaining a legal representative for decision-making but had not secured one for R17. The resident's niece was making healthcare decisions without any legal documentation, and the Social Worker acknowledged that the process to secure guardianship had only just begun. A review of facility documents and relevant legal provisions revealed no documentation authorizing a legal representative for R17, and the facility did not provide any evidence of having secured such representation by the end of the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,230 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Livonia | 2.1 mi | ★★★★★ | 10 | 0 |
| The Manor Of Farmington Hills | 2.3 mi | ★★★★★ | 14 | 0 |
| West Oaks Senior Care & Rehab Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Beaconshire Nursing Centre | 2.5 mi | ★★★★★ | 4 | 0 |
| Regency At Livonia | 2.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Orchards At Redford.
100% money-back within 48 hours.
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.