Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Great Lakes Crossing during CMS and state inspections, most recent first.
Late Lunch Service and Improper Diet Consistencies: During lunch prep, food for residents on mechanical soft and pureed diets was not prepared to the correct consistency, with large stew pieces, pea-sized vegetables, and no pureed meat initially available. Staff had to further process the food while the tray line was underway, and the first lunch cart did not leave the kitchen until well after the scheduled lunch start time.
Kitchen sanitation and resident refrigerator food handling were deficient. Surveyors observed damaged and non-cleanable wall surfaces, a grease-covered light fixture, dusty vents, and ladles stored bowl side up in the kitchen. In resident refrigerators, staff found opened and unlabeled food and beverage items, stained shelving, and a refrigerator temperature of 46 F; the DM, DON, and NHA acknowledged that resident food should be labeled and dated and that the refrigerators should be clean and kept at the proper temperature.
A reach-in cooler in the dietary office was not maintained in good working order. Temperature logs showed repeated elevated temps, the internal thermometer read 47 F, and the left door gasket was found off the door and lying on a shelf, leaving the door ajar. The DM said the unit had been having problems and should be kept between 30-40 degrees, while an AM staff member and the MD reported maintenance had not been notified about the elevated temp and the gasket was needed for a proper seal.
Late and Missing MDS Assessments: The facility failed to complete required MDS assessments on time for 13 of 13 residents reviewed. Several residents had quarterly or annual assessments that were overdue or not completed as required, including residents with diagnoses such as schizophrenia, hemiplegia, CVA, diabetes, epilepsy, Alzheimer's disease, dysphagia, and CKD. The MDS Coordinator acknowledged the assessments were not completed by the due date, and the NHA stated they should be completed as required.
Improper Food Texture Preparation: The facility failed to prepare meat and vegetables to the correct consistency for residents on mechanical soft and pureed diets. During lunch service, the mechanical soft beef stew contained large pieces of meat and potatoes, and the pureed vegetables contained pea-sized pieces. The AM Cook/MiT said, "I was doing too much today," and the DM later stated the cook had been told the food was too chunky and that pureed foods should be smooth and pudding-like.
Missed showers and delayed nail care were identified for two residents. One resident with paraplegia and dependence for bathing reported going over a week without a shower, and record review showed multiple scheduled shower days with no documentation or refusal noted. Another cognitively intact resident with generalized weakness was observed with long fingernails and debris under the nails; staff acknowledged the nails should have been cleaned and trimmed during the resident’s bed bath, but this was not done.
Improper Storage of Refrigerated Medications: Multiple medications in a second-floor med refrigerator were observed at 28 degrees Fahrenheit, and the temp log showed readings between 28 and 30 degrees Fahrenheit over a prolonged period. The DON confirmed the meds had been stored improperly, and the manufacturer guidelines and facility policy required refrigerated meds to be kept at 36 to 46 degrees Fahrenheit.
The facility failed to ensure three of five CNAs completed the required 12 hours of annual training. The HRM found no training records for two CNAs and noted that one CNA lacked required dementia training. The DON stated CNAs were expected to receive annual training that included dementia and abuse content because the facility has numerous residents with dementia.
The facility failed to ensure timely review and submission of PASARR forms for three residents, potentially impacting their mental health care. One resident with schizophrenia lacked a Level II evaluation, another with dementia and mood disorders had incomplete records, and a third resident's evaluation request was rejected due to early submission. The facility's policy on PASARR guidelines was not adhered to, leading to these deficiencies.
A facility failed to develop and implement a care plan for a resident with an indwelling catheter, leading to potential unmet care needs. An LPN was unaware of the catheter's presence, and the care plan only addressed nephrectomy tubes. The resident, with multiple diagnoses and requiring assistance with ADLs, had no care plan for the catheter, as acknowledged by both the LPN and DON.
A resident's oxygen tank was found improperly stored at their bedside, creating a potential hazard. The tank was full and propped between the bed and table without a stand, contrary to facility policy. The resident, who has COPD and other health issues, sometimes adjusts their oxygen flow independently. The facility's policy requires secure storage of medical gas cylinders, which was not followed in this instance.
A resident with an indwelling foley catheter was found without a leg strap, contrary to the facility's urinary catheter policy. Staff interviews confirmed the absence of the strap and acknowledged the risk of catheter pulling, which could cause pain. The resident had intact cognition and was admitted with multiple diagnoses, including pneumonia and congestive heart failure. The facility's policy requires daily checks of catheter straps during AM and PM care.
The facility failed to date respiratory equipment for two residents, compromising safe respiratory care. A resident with intact cognition and another with impaired cognition were both observed with undated nebulizer masks and tubing. An LPN stated that a contracted company changes and dates the equipment weekly, but acknowledged the oversight. The DON confirmed that staff should check daily for accurate dating, as per facility policy.
A resident sustained a fractured tibia and fibula after being transported in a manual wheelchair instead of their usual power wheelchair, which was deemed unsuitable for the transport van. The resident's foot slipped off the pedal during transport, resulting in the injury. The facility's policy required proper assessment for wheelchair use, which was not adequately followed, leading to the incident.
A resident with severe cognitive impairment and multiple medical conditions, including cerebral palsy and osteoporosis, suffered a toe fracture. The facility failed to conduct a thorough investigation into the injury, as the incident report lacked staff interviews and detailed accounts of the event. The DON suggested the fracture occurred spontaneously, but there was no evidence to confirm the timing of the injury. This lack of investigation led to a deficiency citation.
A resident with severe cognitive impairment and a recent toe fracture did not receive timely pain management. Despite showing signs of pain, the first pain medication order was made a day after the fracture was identified. The facility's policy for assessing pain in cognitively impaired residents was not followed, as confirmed by the DON.
A resident with impaired cognitive function experienced a fall, and an x-ray revealed an acute distal tibial fracture. The facility failed to notify the physician of the abnormal results in a timely manner, delaying further treatment. Staff interviews indicated that the physician was texted but not called, and no follow-up attempts were documented. The facility's policy requires immediate notification of changes in a resident's condition to the attending physician.
A resident with dysphagia and nutritional deficiency did not receive tube feeding as per physician orders, leading to potential unmet nutritional needs. Observations showed the feeding pump was not running, and staff interviews revealed the feeding was not documented as given. The DON confirmed the resident should have received 1350cc but only received 815cc. The midnight nurse removed the feeding due to the resident pulling on it, but this was not documented.
Late Lunch Service and Improper Diet Consistencies
Penalty
Summary
Meals were not delivered in a timely manner and were not prepared in accordance with the scheduled mealtimes for residents. During observation of lunch service, the steam table was set with food ready to be served, but the mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls, and the vegetables designated for residents on a pureed diet contained pea-sized pieces. No pans of pureed meat were present when the tray line was being prepared, and the first meal ticket on the tray service line was for a resident on a mechanical soft diet. At 11:50 AM, the Dietary Manager was questioned about the consistency of the food prepared for residents on mechanical soft and pureed diets, and stated the situation had been handled, although the AM Cook/MiT had stepped out of the kitchen. At 12:02 PM, the Regional Dietary Director stated the mechanical soft diet meal trays would have to be hand delivered so the tray line would not be delayed further. When the AM Cook/MiT returned at 12:03 PM, they stated, "I was doing too much today," then obtained the food processor and further processed the mechanical soft beef stew meat and pureed vegetables, and processed stew meat for residents on pureed diets. The first lunch meal cart left the kitchen at 12:13 PM, although the facility's meal times document showed lunch service begins at 11:30 AM, and the Dietary Manager later stated the first lunch cart should leave around 11:45 AM. The Nursing Home Administrator stated the meal being served late was not acceptable because the food was not prepared timely.
Kitchen Sanitation and Resident Refrigerator Food Labeling Deficiencies
Penalty
Summary
The facility failed to keep kitchen wall surfaces in good repair and cleanable condition. During a kitchen tour, the wall behind the clean pot/pan shelving unit showed surface damage and paint loss from repeated impact, and two wall panels beside the three-compartment sink drainboard were detached, exposing the raw block wall behind them. A light fixture cover above the cooking range had visible grease accumulation in suspended droplets, and the Dietary Manager stated the hood and light fixture covers were cleaned once a month and that if something looked like it might drop into food, staff moved the cooking food and cleaned the light fixture. Four ladles hanging from a rack were stored bowl side up, and the Dietary Manager stated dust could collect inside the bowls. The air conditioning vents in the room housing a reach-in cooler, reach-in freezer, and single-service items were also soiled with accumulated dust. The facility also failed to maintain resident refrigerators and food storage practices in a sanitary manner. In the 2nd floor resident refrigerator, surveyors found a 3.7 oz opened and unlabeled container of cheddar cheese sauce, and an LPN stated it was supposed to be dated and have the resident's name on it. In the 3rd floor resident refrigerator, surveyors found an opened and unlabeled 12 oz can of carbonated beverage, stained shelving with dried and sticky substances, and a thermometer reading 46 F. The Dietary Manager stated refrigerators should be maintained between 30-40 F and was unsure who was responsible for cleaning resident refrigerators, while confirming that food stored in resident refrigerators should be dated and labeled with the resident's name. The DON also stated she did not know who was responsible for cleaning the resident refrigerators, and the NHA stated resident refrigerators should be clean, maintained at the correct temperature, and resident food items should be labeled and dated.
Reach-In Cooler Not Maintained in Working Order
Penalty
Summary
The facility failed to ensure the reach-in cooler located in the dietary office was maintained in good working order. During a kitchen tour with the Dietary Manager, the temperature log for the cooler showed AM temperatures of 49 F on 2/15/26, 48 F on 2/16/26, 44 F on 2/17/26, and 45 F on 2/18/26. The thermometer inside the cooler registered 47 F, and the left cooler door gasket was not installed, leaving the door ajar. The gasket was observed lying on top of a metal shelving unit. The Dietary Manager stated the unit had been having a little problem and maintenance had been fixing on it, and said the refrigerator should be maintained between 30-40 degrees with staff contacting maintenance if the temperature was above 40 degrees. An AM staff member stated maintenance did not come to the kitchen regarding the reach-in cooler while they worked the previous day. The Maintenance Director later stated they had not been notified about the elevated temperature and confirmed that a properly installed gasket was necessary to get a proper seal on the cooler door.
Late and Missing MDS Assessments
Penalty
Summary
The facility failed to complete and/or ensure the timely completion of comprehensive resident assessments in accordance with regulatory requirements for 13 of 13 residents reviewed for MDS assessment accuracy and timeliness. The residents identified were R4, R6, R33, R53, R72, R93, R94, R95, R101, R114, R124, R125, and R139. The report states that these assessments were not completed by their due dates or were completed late, including quarterly assessments that were not completed as required and annual assessments that were not completed as required. The residents involved had a range of pertinent diagnoses documented in their records, including schizophrenia, hemiplegia, muscle weakness, cerebral vascular accident, sepsis due to pseudomonas, diabetes, epilepsy, Alzheimer's disease, an injury to the head, dysphagia, and chronic kidney disease. Specific examples included R6's quarterly assessment completed after the due date, R95's quarterly assessment completed after the due date, and R139's discharge assessment not completed as required. During interview, the MDS Coordinator stated that resident assessments were not completed by the due date or finished in a timely manner, and the NHA stated that MDS resident assessments should be completed as required by the regulations.
Improper Food Texture Preparation
Penalty
Summary
The facility failed to prepare meat and vegetables in the proper food consistency for residents receiving mechanical soft and pureed textured meals. During lunch service observation, the steam table contained mechanical soft beef stew with large pieces of stew meat and potatoes approximately the size of golf balls, and vegetables designated for residents on a pureed diet contained pea-sized pieces. When questioned, the AM Cook/MiT stated, "I was doing too much today." The Dietary Manager later stated the AM Cook/MiT had been informed that the stew meat was too large for mechanical soft diets and that pureed vegetables should not be chunky or lumpy, but smooth like mashed potatoes. Facility documents titled Mechanical Soft Diet and Guidelines for Pureed Preparation stated that mechanically soft meat should be mechanically ground unless otherwise indicated and that the pureed diet should have a semi-liquid to semi-solid, pudding-like consistency.
Missed Showers and Delayed Nail Care
Penalty
Summary
The facility failed to provide scheduled showers for one resident and timely nail care for another resident. One resident, admitted with thoracic spinal cord injury, colostomy status, and neuromuscular dysfunction of the bladder, was assessed as cognitively intact and dependent on staff for showering and bathing. The care plan directed staff to assist with ADLs and provide total dependence with bathing on Tuesday and Friday afternoons and as needed. The resident stated he was not getting showers on a regular basis and reported going a week and a half without one, attributing missed showers to low staffing. Review of the record showed shower or bed bath documentation only on a few dates over the prior 30 days, with multiple expected shower days lacking documentation, and no evidence of documented refusals. Staff interviews confirmed that shower sheets should have been completed and that there were no shower sheets available for the resident. A second resident, admitted with generalized osteoarthritis, myalgia, and difficulty walking, was observed with long fingernails and debris under the nails and stated he needed help with care and wanted his nails cut. The resident was cognitively intact and had a care plan directing staff to anticipate and meet daily needs, including hygiene, with total dependence for personal hygiene and bathing on Wednesday and Saturday mornings and as needed. The resident later stated that after receiving a bed bath, the aide did not offer to cut his nails. Staff observed that the fingernails needed to be cleaned and clipped, and an LPN stated the fingernails should have been cleaned and trimmed when the bed bath was given. The DON stated the expectation was that all staff identify and address ADL care, including nail care, on shower days or as needed.
Improper Storage of Refrigerated Medications
Penalty
Summary
Medications stored in the second-floor medication refrigerator were not maintained at the required temperature range. An observation on 2/19/2026 at 2:48 PM found multiple medications in that refrigerator stored at 28 degrees Fahrenheit. Review of the refrigerator temperature log showed recorded temperatures ranging from 28 degrees Fahrenheit to 30 degrees Fahrenheit from February 1 through February 19, 2026. Review of the manufacturer guidelines for the medications stored in that refrigerator showed they were to be kept at 36 degrees Fahrenheit to 46 degrees Fahrenheit. During an interview on 2/20/26 at 11:17 AM, the DON stated that the medication had been stored improperly in the second-floor medication refrigerator. The facility policy titled Medication Storage in the Facility, dated May 2022, stated that refrigerated medications are to be maintained at 36 to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring.
CNA Annual Training Deficiency
Penalty
Summary
The facility failed to ensure that three of five CNAs, identified as CNA O, CNA P, and CNA Q, completed the required 12 hours of annual training. During review of the CNA in-service logs with the HRM, there were no records of training for CNA P or CNA Q, and CNA O did not have the required dementia training. The HRM stated that the trainings were important because staff interact with residents who have dementia. The DON also stated that the expectation was for CNAs to receive 12-hour annual training, including dementia and abuse, because the facility has numerous residents with dementia. Review of the facility policy titled Training Requirements, revised 2/2026, showed that nurse aides must receive no less than 12 hours per year and address the care of the cognitively impaired.
Failure to Ensure Timely PASARR Screening and Documentation
Penalty
Summary
The facility failed to ensure timely review, revision, and submission of Preadmission Screening (PAS) and Annual Resident Review (ARR) forms for mental illness and intellectual disabilities to the local state agency for three residents. This resulted in the potential for these residents not to receive appropriate care and services for their mental health needs. The deficiency was identified during a review of the electronic medical records and interviews with facility staff. For one resident, identified as R13, the facility did not document a Level II evaluation or evidence that such an evaluation was requested for 2024, despite the resident having a diagnosis of paranoid schizophrenia and being prescribed antipsychotic medication. The Corporate Social Worker acknowledged that a determination letter should have been sent by the state agency due to a dementia diagnosis, which was not documented on the necessary forms. Additionally, the facility's records did not include a completed 3878 form for this resident. Another resident, R15, had a diagnosis of unspecified dementia, psychotic disorder, and mood disorder. The facility's records did not include an annual 3877 or 3878 form, and the Corporate Social Worker was unaware that these forms are part of the resident's medical record. For a third resident, R56, the facility failed to complete an annual Level II evaluation by the required date, and the request for evaluation was submitted too early and subsequently rejected. The facility's policy on PASARR guidelines was not followed, leading to these deficiencies.
Failure to Address Indwelling Catheter in Resident's Care Plan
Penalty
Summary
The facility failed to develop, implement, and revise care plans for a resident with an indwelling catheter, resulting in the potential for unmet care needs. During an observation, an LPN was unaware of the presence of the indwelling catheter, mistakenly believing the resident only had nephrectomy tubes. However, the observation confirmed the presence of the indwelling catheter, which was not addressed in the resident's care plan. The resident, who was admitted with multiple diagnoses including encephalopathy, epilepsy, acute kidney failure, dissection of the abdominal aorta, and protein-calorie malnutrition, was cognitively intact and required assistance with activities of daily living. Despite these needs, the care plan lacked any mention of the indwelling catheter, a fact acknowledged by both the LPN and the DON. The facility's policy requires comprehensive, person-centered care plans, but this was not adhered to in this case.
Unsafe Storage of Oxygen Tank at Resident's Bedside
Penalty
Summary
The facility failed to ensure the safe storage of an oxygen tank at the bedside of Resident 54, who was one of three residents reviewed for respiratory care. During an observation, it was noted that the oxygen cylinder was propped between the resident's bed and bedside table without a stand, creating a potential environmental hazard. The oxygen cylinder was full, as indicated by the gauge, and if it were to fall, it could become a dangerous projectile due to the high-pressure release of oxygen. Resident 54, who was observed sitting in a wheelchair with nasal cannula oxygen tubing, mentioned needing the oxygen to breathe and sometimes adjusting the oxygen flow themselves when experiencing shortness of breath. The resident's medical record indicated a diagnosis of Chronic Obstructive Pulmonary Disease, Anxiety, Difficulty Walking, and Muscle Weakness, with a cognitive assessment showing intact cognition. The facility's policy on medical gas cylinder storage requires that all cylinders be physically supported to prevent mechanical hazards. However, the staff failed to adhere to this policy, as evidenced by the inappropriate storage of the oxygen cylinder. The Nursing Home Administrator acknowledged that staff were responsible for ensuring the safe storage of oxygen equipment, but this was not followed in the case of Resident 54.
Deficiency in Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling foley catheter, leading to a deficiency in catheter care. On January 13, 2025, the resident was observed without a leg strap to secure their catheter, which could potentially cause irritation or trauma. The resident, who was admitted with diagnoses including pneumonia, congestive heart failure, dysphagia, muscle weakness, and bipolar disorder, had intact cognition as per their BIMS score. Interviews with staff, including a CNA, a wound care nurse, and an LPN, confirmed the absence of a leg strap and acknowledged the risk of catheter pulling, which could cause significant pain. The Director of Nursing stated that catheter straps should be checked daily during AM and PM care. The facility's urinary catheter policy from March 2014 requires the use of a leg strap secured to the inner thigh to prevent catheter movement and friction at the insertion site.
Failure to Date Respiratory Equipment for Residents
Penalty
Summary
The facility failed to date respiratory equipment for two residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident 16 was observed with a nebulizer mask and connecting tubing that were not dated. This resident had a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia, Muscle Weakness, and Bipolar, with intact cognition as indicated by a BIMS score of 15/15. Licensed Practical Nurse (LPN) A mentioned that a contracted respiratory company is responsible for changing and dating the tubing every Friday. Similarly, Resident 9 was observed with undated nebulizer equipment. This resident had a diagnosis of Sepsis, Respiratory Failure, Dysphagia, Failure to Thrive, Muscle Weakness, and Depression, with impaired cognition as indicated by a BIMS score of 0/15. LPN A acknowledged that the nebulizer mask should have been dated. The Director of Nursing (DON) confirmed that the facility has a policy requiring staff to check daily to ensure all tubing is accurately dated, and that a company comes weekly to change and label respiratory tubing. The facility's policy from July 2015 mandates that respiratory supplies be routinely changed or cleaned to prevent infections, with nebulizers to be changed weekly or as needed, and all supplies dated upon opening.
Inappropriate Wheelchair Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the use of an appropriate wheelchair for a resident, resulting in a fractured tibia and fibula. The incident occurred when two CNAs transferred the resident into a manual wheelchair for a medical appointment, despite the resident's usual use of a power wheelchair. The power wheelchair was deemed unsuitable for transport in the van, leading to the decision to use a manual wheelchair instead. During the transport, the resident's foot slipped off the wheelchair pedal multiple times, eventually getting caught under the chair, which resulted in the fractures. The resident had previously been evaluated and found unable to propel a manual wheelchair due to decreased active range of motion and strength in the lower extremities. The facility's policy required residents to be assessed for the appropriate type and size of wheelchair, but it appears this was not adequately followed in this case. Interviews with staff revealed that the decision to use a manual wheelchair was made because the power chair would not fit in the transport van, and a geri-chair could not be safely secured. Despite the resident's complaints of pain during the transport, they were sent to their appointment, and it was only upon their return that the injury was fully recognized. The facility's failure to provide an appropriate means of transport directly contributed to the resident's injury.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, leading to a deficiency citation. An anonymous complaint alleged that the facility improperly transferred a resident, resulting in a broken toe. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral palsy and osteoporosis, was observed in a wheelchair with a protruding tongue and did not respond verbally. A progress note indicated that the resident experienced pain in the left foot, leading to an x-ray that revealed a fracture. However, the facility's incident report lacked a thorough investigation, as it did not include interviews with staff or a detailed account of the events leading to the injury. The Director of Nursing (DON) reviewed surveillance footage and suggested the fracture occurred spontaneously when an activity aide placed the resident's feet on the wheelchair pedals. However, there was no evidence to confirm whether the fracture occurred before or after the resident was taken to the activity room. The facility's policy on abuse and injuries of unknown source mandates prompt and thorough investigations, which was not adhered to in this case. The lack of a comprehensive investigation into the incident and the absence of staff interviews contributed to the deficiency finding.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to appropriately assess and manage pain for a resident with severe cognitive impairment, identified as R903. On December 11, 2024, R903 was observed in a wheelchair with their tongue protruding and unable to engage in verbal communication. The resident had a history of cerebral palsy, nutritional deficiency, protein calorie malnutrition, aphasia, and heart failure, with a recent Minimum Data Set assessment indicating severely impaired cognition. On November 22, 2024, a nurse's note documented that an activity aide reported the resident experiencing pain in their left foot, with facial grimaces and moaning upon assessment. An x-ray was ordered, revealing an acute second metatarsal neck fracture. Despite the discovery of the fracture and the resident's demonstrated pain, the facility's records showed that the first order for pain medication was not made until November 23, 2024, a day after the fracture was identified. No pain medication was administered on the day the fracture was discovered. The Director of Nursing confirmed that a numerical pain scale was not appropriate for R903 due to their cognitive impairment, yet no evidence was provided to show that pain medication was administered following the discovery of the fracture. The facility's pain management policy indicated that residents with cognitive impairments should be evaluated using objective observations, such as the PAINAD scale, but this was not adhered to in R903's case.
Failure to Timely Notify Physician of Abnormal X-ray Results
Penalty
Summary
The facility failed to inform the physician of an abnormal x-ray result in a timely manner for a resident who experienced a fall. The resident, who had moderately impaired cognitive function and required substantial assistance with activities of daily living, fell on 7/25/24. An x-ray was ordered and completed the same day, revealing an acute distal tibial fracture. However, the results were not communicated to the physician until 7/30/24, resulting in a delay in further treatment. Interviews with staff revealed that the physician was initially texted about the x-ray results but not called, and there was no documentation of follow-up attempts to contact the physician. The Director of Nursing acknowledged that the nursing staff should have made more attempts to contact the physician and documented any communication. The facility's policy requires immediate notification of changes in a resident's condition to the attending physician, which was not adhered to in this case.
Failure to Administer Tube Feeding Per Physician Order
Penalty
Summary
The facility failed to administer tube feeding per physician order for a resident, resulting in the potential for nutrition needs not being met and unintended weight loss. During an observation, it was noted that the resident's tube feeding was not running, and the pump did not have formula or water hanging. The resident had been admitted with diagnoses including dysphagia and nutritional deficiency and required a feeding tube as per their Minimum Data Set (MDS) assessment. Physician orders specified that the resident should receive enteral feeding with Jevity 1.5 at 75cc/hr for 18 hours, totaling 1350cc, along with an auto flush of 25cc/hr for 18 hours. Interviews with staff revealed that the tube feeding was not documented as given on a specific date, and the resident did not receive the full prescribed amount before the feeding was stopped. The Licensed Practical Nurse (LPN) and Unit Manager both stated they did not remove the resident from the tube feeding. The Director of Nursing (DON) confirmed the discrepancy in the amount fed and acknowledged that the resident should have received the full 1350cc. The DON later reported that the midnight nurse had removed the resident from the tube feeding because the resident was pulling on it, but this removal was not documented in a progress note.
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 1,232 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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Heights-detroit | 0 mi | ★★★★★ | 0 | 0 |
| West Oaks Senior Care & Rehab Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Beaconshire Nursing Centre | 1.7 mi | ★★★★★ | 4 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 23 | 0 |
| Oakland Nursing Center | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.