Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Wellbridge Of Rochester Hills during CMS and state inspections, most recent first.
Incomplete investigation of unwitnessed right leg fractures: A resident with dementia, Parkinson’s disease, severe cognitive impairment, and an AKA developed large bruising and pain in the R lower leg, and imaging showed acute comminuted tibia and fibula fractures. The facility’s investigation found no reported falls or trauma and attributed the injury to malignancy, osteoporosis, and alleged repetitive striking of the leg, but there was no documentation supporting that behavior, no clear explanation for the injury, and key staff from the day the change in condition was noted were not interviewed.
A resident with a recent femur fx, severe cognitive impairment, and dependence for most ADLs developed worsening R hip pain and inability to ambulate during therapy. Therapy staff reported the change to nursing, but the record did not show a timely nurse assessment or MD notification that day. A STAT R hip x-ray was later ordered after family concern and showed dislocation of the hip arthroplasty, and a separate UA ordered for suspected UTI also lacked timely nursing follow-up.
A resident with dementia, sarcopenia, a Stage II coccyx pressure ulcer, a right elbow abrasion, and a ruptured blister on the heel received wound treatments ordered by the attending physician, but there was no documentation that any physician ever assessed or evaluated these wounds. Nursing staff documented wound findings, took photos, and implemented treatment orders, while the DON described a process in which nurses and the IDT, but not the physician, routinely reviewed wound progress. The facility’s pressure ulcer policy required physician participation in defining ulcer characteristics, identifying contributing factors and medical interventions, and documenting wound healing during visits, yet physician progress notes on multiple visits omitted any wound assessment, and the attending physician later confirmed being unable to locate any such documentation in the record.
A resident with severe cognitive impairment, on hospice and dependent for all ADLs, reported that someone entered the room with their face covered, turned off the lights, and removed a wedding ring from her finger. An activities assistant relayed this allegation to an LPN, who searched the room and contacted the resident’s daughter to ask about the ring but did not disclose the resident’s report of theft or immediately notify the Abuse Coordinator. When the daughter arrived, the resident again reported that someone had stolen the ring, which the nurse overheard, but no prompt follow-up occurred, leading the daughter to call police. Law enforcement later advised that the ring had been pawned and that the ID used matched a CNA who had worked that day, while clinical notes documented bruising to the resident’s left ring finger and hospice records referenced an incident causing bruising and swelling. The facility had a policy prohibiting misappropriation of resident property and defining misappropriation as the deliberate wrongful use of a resident’s belongings without consent.
A cognitively impaired hospice resident reported that someone with a covered face entered her dark room, turned off the lights, removed her wedding ring from her finger while she yelled for help, and left. An activity assistant immediately told an LPN, but the LPN searched the room and called the resident’s daughter to ask if she had the ring instead of promptly reporting the allegation of abuse and misappropriation to the Administrator/Abuse Coordinator and authorities as required by facility policy and Section 1150B. The DON, after being informed of the allegation, instructed the LPN to continue searching the room due to the resident’s cognitive status, and the Administrator later stated they initially believed the ring was simply lost and did not timely notify the State Agency or law enforcement. Documentation submitted to the State omitted key details of the resident’s allegation and the bruising later documented on the resident’s ring finger, and no psychosocial or social work assessment was completed despite the Administrator’s report that one had been done, resulting in a failure to implement abuse/misappropriation policies and to accurately and timely report the incident and investigation findings.
A staffing breakdown on the overnight shift led to missed meds, treatments, blood sugar checks, and other ordered services for multiple residents after an LPN stayed late to help with med pass and the scheduled midnight nurses did not fully take over the assignment. MAR/TAR review showed omitted pain meds, insulin-related checks, respiratory meds, anticoagulants, enteral feedings, wound care, and other treatments, while interviews confirmed the nurses refused parts of the assignment and the DON did not learn of the missed care until the next morning. One resident also reported needing to use the restroom without assistance because staff were passing breakfast trays.
Failure to Provide Advance Directive Information: The facility failed to provide a resident and the resident’s POA with information about advance directives and failed to offer the opportunity to formulate one. The resident had CKD, colostomy status, and sepsis, and the record showed no documentation that staff provided the required information or discussion. Interviews reflected confusion between CT, nursing, and social work regarding who was responsible for providing advance directive information.
A resident with diabetes, dementia, stroke, hospice services, a Stage 2 sacral pressure ulcer, and a new left heel wound was observed seated in a high-back wheelchair without an adequate pressure-relieving cushion and with the left foot sliding on the footrest so the heel struck the metal footplate. Staff and the DON confirmed the resident initially lacked a wheelchair cushion, and the heel wound was later documented as a new diabetic foot ulcer with surrounding redness. The care plan did not include a wheelchair cushion, and the resident was also observed sacral sitting with a full-body lift sling underneath.
Failure to Assist Resident With Hearing Aids: A resident with dementia and total ADL dependence was observed unable to hear the surveyor and stated staff would need to provide the hearing aids because they were in a nightstand drawer and out of reach. The record had no active care plan for the hearing deficit or documentation of the hearing aids, and the DON stated the aids or nurses could assist with applying them.
A resident dependent on two-person assist for bed mobility fell from bed during care when one CNA stepped away, leaving the resident on their side, resulting in a fall and reported pain. In a separate incident, another resident with cognitive impairment and exit-seeking behavior eloped from the facility after staff failed to respond to a wander guard alarm, allowing the resident to leave unsupervised with a visitor. Both deficiencies were due to lapses in supervision and failure to follow safety protocols.
A resident with severe cognitive impairment and complex medical needs did not receive full showers as requested by her legal decision maker, who had clearly communicated that bed baths were not to be substituted. Despite these instructions, the resident received a bed bath instead of a scheduled shower, and the care plan did not specify the requirement for showers only, resulting in care not aligned with the expressed preferences.
A resident with diabetes experienced a prolonged delay in receiving insulin after reporting a high blood sugar level. Despite repeated requests and elevated glucose readings, the LPN and supervisor waited several hours for a provider response before administering additional insulin, contrary to facility protocols and expectations for timely intervention.
The facility did not adequately supervise or implement individualized fall prevention interventions for two residents with severe cognitive impairment and high fall risk, resulting in repeated falls, injury, and hospitalization. Required safety devices were missing from a resident's wheelchair, and a hot liquid spill incident involving another resident was not investigated or documented. Staff relied on generic interventions for all new admissions, and the facility's accident policy was outdated and incomplete.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who was caught on camera hitting the resident's hand and calling them 'Grumpy.' The incident was reported after a family member placed a camera in the room due to suspicions of abuse. The facility's Administrator confirmed viewing the footage and reeducating the CNA on communication and abuse policies.
The facility failed to ensure safe transfer practices, resulting in multiple resident injuries. One resident fell during a toilet transfer, fracturing their tibia, while another experienced repeated Hoyer lift incidents leading to hospital visits. Additionally, a cognitively impaired resident was improperly transported, causing leg pain. The facility's inadequate investigations and lack of proper transfer techniques contributed to these deficiencies.
A long-term care facility failed to ensure proper medication administration, resulting in errors for three residents. A nurse mistakenly gave Xanax to a resident without an order for it after preparing medications for two residents at once. The facility lacked complete documentation for the incidents, and the Director of Nursing confirmed awareness of the errors. The facility's policy on medication-related problems was not followed, leading to these deficiencies.
Two residents in the facility experienced untreated skin conditions due to a lack of proper assessment and documentation. One resident had visible venous ulcers on the feet, with no treatment provided despite physician orders. Another resident reported persistent itching and irritation, requesting Nystatin powder, but received no care. The DON and nursing staff failed to follow skin management policies, resulting in untreated conditions.
The facility failed to secure controlled substances in the 400-Hall due to a broken lock on the medication box, affecting all residents with prescribed controlled substances. A discrepancy in the count of Klonopin was noted, and staff interviews revealed awareness of the issue, but medications were not moved to a secure box. The facility's policy requires double-locked storage for controlled substances.
A resident's clonazepam medication count was found to be incorrect, with two tablets unaccounted for, indicating a failure to prevent misappropriation. The discrepancy was discovered during routine medication counts by LPNs and an RN, but the facility's investigation was inconclusive. The resident had a history of anxiety, dementia, and bipolar disorder.
A resident experienced multiple falls and made an allegation of abuse, resulting in a wrist fracture that was not identified and treated in a timely manner. Despite complaints of pain and visible swelling, the facility did not seek diagnostic tests until weeks later, leading to delayed treatment.
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident admitted with a right femur fracture and hypertension. Despite initial documentation of red, slow-to-blanch, boggy heels and a red, blanching sacrum and coccyx, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments until 10 days later. Interviews revealed that medical professionals relied on nursing staff to notify them of wound issues, contrary to the facility's policy on physician services.
Incomplete investigation of unwitnessed right leg fractures
Penalty
Summary
The facility failed to complete a thorough investigation for an injury of unknown origin involving a resident who had severe cognitive impairment, dementia, Parkinson’s disease, and an above-the-knee left leg amputation. The resident was dependent on staff for all ADLs, required extensive assistance, and used a mechanical lift for transfers. A complaint to the State Agency alleged the resident sustained a broken right leg without a clear explanation, and the resident could not recall how the injury occurred when interviewed. The medical record showed the resident had no documented right leg injury on admission, but later developed increased lethargy and decreased appetite. Staff then observed a large bruise on the right lower leg and bruising on the left stump, with pain on movement, warmth, and edema. X-rays and CT imaging identified acute comminuted impacted proximal tibial shaft fractures and comminuted proximal fibular shaft fractures of the right leg. Hospital documentation described the injury as an unwitnessed injury, and noted there were no reported falls or trauma from the facility or family. The facility’s investigation stated there were no falls, injuries, or incidents reported in the prior 24 to 48 hours and attributed the fractures to factors such as malignancy, osteoporosis, diffuse bone demineralization, and alleged repetitive striking of the right lower extremity against the left stump or objects. However, the record contained no documentation that the resident had previously struck the leg or stump, and the care plan did not identify such behavior. The Administrator, DON, and Regional Director Consultant confirmed they completed the investigation together but could not explain how the resident sustained the fractures. They also acknowledged they did not interview staff from the day the change in condition was noted and the day the resident received a shower, and no additional information or documentation was provided before the end of the survey.
Delayed assessment and diagnostics for resident with worsening hip pain
Penalty
Summary
The facility failed to assess and implement interventions and diagnostics in a timely manner for one resident who had a change in condition involving increased right hip pain and later a dislocated right hip arthroplasty. The resident had been admitted for rehabilitation after hospitalization for a fall with a right femur fracture and had significant cognitive impairment, requiring assistance with most activities of daily living. Therapy notes documented that the resident was participating in therapy on 3/17/26, but by 3/19/26 the resident reported right hip pain during standing and was unable to ambulate because of pain. On 3/20/26 therapy again documented that the resident complained of pain with weight shifting, could not take steps because of pain, and nursing was notified. The record did not show a nurse assessment or physician contact on 3/20/26 after therapy reported the increased pain and inability to ambulate. Family members also reported that the resident’s right foot and hip looked turned out and that the resident had more pain. On 3/21/26 therapy documented increased pain, recommended gentle positioning and pain management measures, and noted nursing was aware of the resident’s complaints. Later that morning, the provider was contacted and ordered a STAT x-ray of the right hip because the family requested imaging due to the resident’s pain and refusal to allow touch to the right lower extremity. The x-ray was completed on 3/22/26 and showed superior lateral dislocation of the right hip arthroplasty. The resident was not sent to the emergency room until 3/23/26 after the x-ray results were reviewed. The record also showed a urinalysis ordered on 3/16/26 for suspected UTI, but there was no follow-up from nursing on the initial diagnostic order until a second order was placed on 3/22/26. Surveyor interviews with therapy staff and a nurse confirmed that therapy had reported the resident’s increased pain and inability to ambulate on 3/20/26, while the nurse stated they did not call the physician and did not recall completing the expected assessment.
Failure to Ensure Physician Assessment and Documentation of Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of pressure ulcers and wound care for one resident when the facility failed to ensure physician evaluation and assessment of wounds as required by its own policy. The resident was readmitted with dementia, sarcopenia, a Stage II pressure ulcer to the coccyx, and a right elbow abrasion, and required staff assistance for all ADLs. Progress notes documented these wounds, and a subsequent nursing note described the resident verbalizing discomfort in the right heel, with assessment revealing a pre-existing ruptured blister; wound pictures were taken and treatment orders were implemented per protocol under the direction of the attending physician. However, physician examinations documented on multiple dates did not include any evaluation or assessment of these wounds. Further record review showed that, despite multiple wound treatments being ordered under the attending physician’s directive, there was no documentation that any physician examined or assessed the wounds or evaluated the effectiveness of the ordered treatments. The facility’s written policy on Pressure Ulcers/Skin Breakdown required that the physician and staff examine the skin of new admissions for ulcerations, that the physician help define the type and characteristics of ulcers, identify contributing factors and medical interventions, and evaluate and document wound healing progress during resident visits. In interviews, the DON stated that nursing staff assess wounds, take pictures, notify the physician for treatment orders, and that the interdisciplinary team, excluding the physician, reviews wound progress and contacts physicians if treatments are not effective, and also stated they had no control over what physicians document. The attending physician reported that they usually assess wounds when notified but, upon reviewing the resident’s record, could not find any documentation of wound assessment or evaluation, and no further documentation was provided by the end of the survey.
Failure to Protect Resident From Misappropriation of Property and to Properly Respond to Theft Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to respond appropriately to an allegation that a staff member stole the resident’s ring. The resident, who was readmitted with senile degeneration of the brain, chronic atrial fibrillation, was on hospice care, bedbound, dependent for all ADLs, hard of hearing, and had a BIMS score of 5 indicating severely impaired cognition, reported that someone entered the room with their face covered, turned off the lights, and removed the ring from her finger. An activities assistant reported this allegation to an LPN after lunch and before 4 PM. The LPN acknowledged being told that the resident said someone took the ring off her finger and that the person had something dark over their face. Instead of immediately reporting the allegation of theft and potential abuse/misappropriation to the facility’s Abuse Coordinator as required by policy, the LPN first searched the resident, the bed, and the room for the ring and then called the resident’s daughter to ask if she had taken it, without informing the daughter of the resident’s allegation that someone had stolen the ring. The LPN stated they wanted to “go through all of my options” before reporting the allegation. The daughter later arrived at the facility and, upon entering the room, the resident told her that someone had stolen the ring under the circumstances described above. The nurse was present in the doorway and heard this report but there was no documented immediate follow-up with the family in the room regarding the allegation. The daughter, after waiting without further follow-up from facility staff, contacted the police, who initiated an investigation. Law enforcement later informed the daughter and the Administrator that the ring had been taken from the resident and pawned, and that the identification used at the pawn shop matched that of a CNA who had worked at the facility on the date of the incident. The resident’s finger was later noted by a physician to have bruising on the left ring finger, and hospice documentation referenced an incident resulting in bruising and swelling of the left fourth digit, with an x-ray ordered to rule out fracture. Facility investigation statements confirmed that the activities assistant and LPN were aware of the resident’s report that someone with a covered face had taken the ring from her finger, and that the facility had a written policy prohibiting misappropriation of resident property and defining misappropriation as the deliberate wrongful use of a resident’s belongings without consent.
Failure to Timely Report and Accurately Investigate Alleged Theft and Abuse Involving a Resident’s Ring
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and misappropriation policies and to timely and accurately report a reasonable suspicion of a crime and the findings of its investigation to the State Agency (SA) and law enforcement, as required by Section 1150B of the Act. A cognitively impaired resident (BIMS 5/15), dependent on staff for all ADLs and under hospice care, reported that someone entered her darkened room with their face covered, turned off the lights, and removed her wedding ring from her finger while she yelled for help. The activity assistant who first heard the allegation immediately informed the LPN, but did not notify the Administrator/Abuse Coordinator directly, despite facility policy requiring staff to report any incident or suspicion of abuse, neglect, or misappropriation of property to the Executive Director (Administrator) or, in their absence, the DON immediately. After being informed by the activity assistant, the LPN chose to search the resident’s room and contact the resident’s daughter to ask if she had the ring, instead of immediately reporting the allegation of theft and possible abuse to the Abuse Coordinator and authorities. The LPN did not inform the daughter of the resident’s allegation that someone had stolen the ring off her finger. The LPN later notified the DON and Administrator of the resident’s report that someone with a covered face took the ring in the dark room, but the DON directed the nurse to continue searching the room because of the resident’s cognitive state, to make sure the resident was not hallucinating or dreaming. The Administrator stated that, even after being informed that the resident said someone took the ring off her hand, they initially thought the ring was lost and therefore did not promptly notify the SA or law enforcement as required. The Administrator also acknowledged that the daughter, not the facility, contacted the police, and that they did not consider the situation to be of much concern initially. The facility’s internal documentation and reporting to the SA were incomplete and inaccurate. The initial report to the SA noted a missing ring and that authorities were notified, but omitted the resident’s detailed allegation that someone entered her dark room with their face covered and removed the ring from her finger while she yelled for help. A skin assessment completed on the date of the incident documented no abnormal findings and contained no photos of the resident’s hand, despite the daughter later providing photos to the SA showing a dark maroon/purple bruise on the dorsal aspect of the resident’s left ring finger, and a physician note a few days later documenting bruising of that finger. The Administrator’s investigation summary submitted to the SA did not include the allegation details or the bruising, and the Administrator could not explain the omission. Additionally, although the Administrator reported to the SA that a psychosocial assessment had been completed, the medical record contained no psychosocial or social work assessments for the resident in the month of the incident or the following month, and the social worker confirmed that no formal psychosocial assessment (such as PHQ-9) was performed. These actions and omissions demonstrate the facility’s failure to follow its abuse/misappropriation policy and to report the allegation and investigation findings accurately and within the required time frames. The resident’s daughter reported that she was first contacted by a nurse asking if she had the ring and that she was not informed by staff that her mother had alleged someone stole the ring off her finger; she only learned of the allegation directly from the resident upon arriving at the facility. The daughter stated that the LPN heard the resident’s allegation in the doorway and said they were going to report it to the nurse manager, but no one returned to follow up, leading the daughter to call the police herself. The police later informed the daughter that the ring had been found at a pawn shop and that the identification used to pawn the ring matched that of a CNA who had worked at the facility on the date of the incident. The Administrator acknowledged that the case remained under police investigation. Throughout this sequence of events, the facility did not adhere to its policy requiring immediate reporting of suspected abuse or misappropriation to the Executive Director or DON, nor did it ensure timely, complete, and accurate reporting to the SA and law enforcement as required by regulation and facility policy.
Missed Medications and Treatments Due to Overnight Staffing Breakdown
Penalty
Summary
The facility failed to protect residents from neglect when staffing breakdowns on the midnight shift resulted in missed medications and treatments for multiple residents. A complaint alleged that there were no nurses on the 200 and 400 hallways and that residents did not receive night medications. Record review confirmed multiple omitted medications, treatments, blood sugar checks, and other ordered services for residents on the 100, 200, and 400 halls during the overnight shift, with several entries left blank or unsigned on the MAR/TAR and confirmed by medication audit reports. Interviews showed that one day-shift LPN stayed late to help pass evening medications after a call-in, but when she left, the two scheduled midnight nurses did not take over the assignment as expected. One nurse reported that the other refused to count the medication cart and take the keys, and that the hall assignments were not completed as planned. The DON stated that no medications or treatments should have been missed and that the nurses were experienced enough to work together to complete all tasks, but she did not learn of the missed care until the next morning. The missed care affected residents with significant medical needs, including pain management, insulin coverage, anticoagulants, respiratory treatments, enteral feeding, tracheostomy and PEG site care, wound care, and vital sign monitoring. Examples included omitted morphine, Norco, oxycodone-acetaminophen, gabapentin, hydroxyzine, hydralazine, clonidine, Eliquis, insulin-related blood sugar checks, inhaled respiratory medications, tube feeding, and ordered treatments. One resident reported having to use the restroom without staff assistance because aides were passing breakfast trays, and the DON acknowledged that patient care should still occur during mealtimes and that the facility needed to work on its breakfast procedures.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding advance directives and failed to offer the resident and/or the resident representative the opportunity to formulate an advance directive for one resident. R56 was initially admitted to the facility and later readmitted on 11/7/25. The resident’s diagnoses included chronic kidney disease, colostomy status, and sepsis. On 12/9/25, R56 was observed in the room sitting in a wheelchair, and the medical record showed the resident’s brother was the POA for care and financial matters. Review of the medical record found no documentation that facility staff provided R56 or the brother with information about advance directives, and no documentation that the resident or POA was offered the opportunity to formulate one. During interviews, CT personnel stated their department only ensured advance directives were in the medical record and that nursing was responsible for providing the information, while the DON stated nursing was not responsible and that social work/care transitions was responsible. The facility policy stated that prior to or upon admission, the Social Services Director or designee would provide written information to the resident concerning the right to formulate advance directives.
Failure to Provide Adequate Wheelchair Positioning and Pressure Relief
Penalty
Summary
The facility failed to provide adequate positioning for a resident with a Stage 2 sacral pressure ulcer and a new left heel wound. The resident had diagnoses including diabetes, dementia, falls, and stroke, and was receiving hospice services. The care plan identified use of a high back wheelchair and a full body mechanical lift for transfers, but it did not include a wheelchair cushion in the ADL or skin management sections or elsewhere in the current care plan. The resident was observed seated in the wheelchair with a full body mechanical lift sling underneath and no wheelchair cushion visible, while sacral sitting in the chair. The resident’s record showed an active wound treatment order for the buttock wound, confirming the pressure ulcer was still present and not healed. During observations, the resident was repeatedly seen with the left foot positioned on the wheelchair footrest foot plate and sliding so that the left lateral heel struck the metal footplate directly. The resident was not wearing heel protectors or PRAFO boots during these observations. The resident later communicated pain in the foot, and family and surveyor observed a half-dollar sized wound on the left lateral heel with surrounding redness extending up the foot and calf. Nursing staff confirmed the wound was new, and the wound note documented a new diabetic foot ulcer on the left lateral heel. Interviews with CNA staff, the hospice RN, the PT, and the DON confirmed the resident had not been using a wheelchair cushion initially and that the footrest positioning concern had not been identified by nursing staff before the heel wound was discovered. The physician later documented redness to the left foot and lower leg and noted the resident had a prior heel callus that had healed and now appeared worsened again. The physician then ordered a wheelchair air cushion and a padded foot buddy for the wheelchair footrests. The facility policy required assessment and documentation of risk factors, support surfaces, and wound characteristics, and the report cited literature stating air-cell cushions provide optimal pressure relief and shear reduction.
Failure to Assist Resident With Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received assistance with hearing aids to maintain hearing ability. R89 was observed lying in bed on 12/9/25 and again on 12/10/25, and during both encounters the resident stated they were unable to hear the surveyor. The surveyor had to speak into the resident’s right ear to complete the interview. A sign on the resident’s wardrobe indicated the resident had new hearing aids, and on 12/10/25 the resident stated the hearing aids were in the drawer of the nightstand but could not be reached and that staff would have to provide them in order for the resident to put them in. Record review showed R89 was initially admitted to the facility and later readmitted on 6/9/25, with diagnoses including dementia and a need for staff assistance with all ADLs. The record contained no active care plan addressing the resident’s hearing deficit or identifying which staff were responsible for assisting with application of the hearing aids. There was also no documentation of the resident’s hearing aids. During interview, the DON stated that the aids or nurses were both capable of assisting the resident with the hearing aids.
Failure to Prevent Resident Fall and Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bed mobility and required a two-person assist, fell from their bed during routine care. The incident happened while two CNAs were providing in-bed care after the resident had a bowel movement. One CNA stepped away from the bedside to retrieve gloves, leaving the resident positioned on their side facing the door. During this moment, the resident rolled off the bed and was guided to the floor by staff. The resident, who had cognitive impairment, end-stage renal disease, and an above-knee amputation, reported pain in the head and shoulder and was sent to the hospital for evaluation due to being on blood thinners. The root cause was identified as a failure to maintain safe bed mobility during care, specifically not ensuring the resident was safely positioned before a staff member left the bedside. Another deficiency was identified when a resident with moderate cognitive impairment and a history of exit-seeking behavior eloped from the facility without staff knowledge. The resident was able to leave the premises with a visitor, who pushed the resident in a wheelchair out the front door. Although the resident's wander guard security alert activated the door alarm, staff did not respond in a timely manner. Witness statements revealed that staff assumed the resident was with a family member and turned off the alarm without verifying the resident's whereabouts. The resident was later found outside the facility at a nearby apartment complex by police and emergency services, unharmed. In both cases, the deficiencies were directly related to lapses in supervision and failure to follow established safety protocols. In the first incident, staff did not maintain appropriate supervision and positioning during care for a dependent resident. In the second incident, staff failed to respond appropriately to a wander guard alarm and did not follow the facility's elopement policy, resulting in a resident leaving the facility unsupervised.
Failure to Honor Resident's Bathing Preferences as Directed by Legal Decision Maker
Penalty
Summary
The facility failed to provide care in accordance with the expressed preferences of a resident's legal decision maker regarding bathing routines. The legal decision maker had clearly communicated, both verbally and in writing, that the resident was to receive full showers at least twice a week and that bed baths were not to be substituted for showers under any circumstances. Despite these instructions, documentation and interviews revealed that the resident received a bed bath instead of a scheduled shower, and there was no evidence that a shower was provided on the next scheduled day. The resident's care plan did not specify the requirement for full showers only, and the CNA documentation did not reflect that showers were consistently provided as requested. The resident in question had a history of End Stage Renal Disease and Parkinson's Disease, with severely impaired cognition, and was dependent on staff for all bathing activities. The resident was unable to clearly communicate her preferences regarding showers due to a language barrier and cognitive impairment. The legal decision maker had offered to assist with communication if the resident appeared to refuse showers, but staff did not consistently contact the family as requested. Records showed that the last documented shower occurred several days prior to the incident, and subsequent documentation indicated a refusal but did not show that the family was contacted or that further attempts were made to provide a shower as per the care plan. The facility's documentation practices and care planning failed to reflect the specific bathing preferences, leading to the resident not receiving care in accordance with the legal decision maker's wishes.
Delayed Insulin Administration for High Blood Sugar
Penalty
Summary
A resident with type 2 diabetes, who was admitted to the facility and had intact cognition, experienced a significant delay in receiving appropriate treatment for a high blood sugar episode. On the evening in question, the resident's blood sugar was measured at 420 mg/dl at 9:00 PM. The resident requested insulin, but the nurse on duty stated she could not administer additional insulin without a physician's order. The nurse attempted to contact the on-call health care provider but did not receive a response for several hours. During this period, the resident continued to experience elevated blood sugar levels, with subsequent readings remaining high. The nurse and supervisor informed the resident that they were waiting for a response from the provider and could not administer more insulin due to the lack of specific orders and the risk of hypoglycemia. The resident did not receive the necessary insulin to address the high blood sugar until approximately 2:00 AM, about five hours after the initial report of the elevated level. Facility records and interviews confirmed that the process for escalating care in the event of a delayed provider response was not effectively followed. Both the DON and another RN indicated that a timely response from a provider should occur within 30 minutes to an hour, and that further steps could have been taken to contact another provider or escalate the situation. Facility policy also required timely provider response and escalation if needed, but these protocols were not adhered to, resulting in a prolonged period before the resident received appropriate treatment.
Failure to Prevent Accidents and Implement Resident-Specific Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for residents at high risk for falls. One resident with severe cognitive impairment and a history of falls was admitted following a hospital stay for a fall-related injury. Despite being identified as high risk for falls, this resident was only provided with generic fall prevention interventions upon admission, which did not address their specific needs or cognitive limitations. The care plan did not include individualized interventions, and the facility did not incorporate information from the hospital indicating the need for a 24-hour sitter. The resident experienced multiple falls in common areas, including the dining room, resulting in a hip fracture and head injury. Family members reported a lack of staff supervision in the dining room, and staff interviews confirmed that only standard interventions were implemented for new admissions, regardless of risk level. Another resident with significant cognitive impairment and a high risk for falls was observed without required safety devices on their wheelchair, such as anti-tip bars and dycem, despite these being listed as care plan interventions. The resident's call light was also found to be inaccessible due to a broken clip. Staff interviews revealed a lack of knowledge about how to access or implement care plan interventions, and the regional nurse consultant confirmed that the required safety devices were not in place. Observations over multiple shifts showed that the resident remained without these interventions, and staff were unaware of the missing equipment until it was pointed out by surveyors. Additionally, the facility failed to investigate an incident in which a resident with cognitive deficits spilled hot coffee on themselves in the dining room. This event was witnessed by a family member and a staff member, but the Director of Nursing was unaware of the incident and no investigation or documentation was found. The facility's policy on accidents and incidents was outdated and did not address the process for fall risk assessment, implementation of resident-specific interventions, or monitoring of interventions. Interviews with unit managers and the DON confirmed that only generic interventions were implemented upon admission, with resident-specific interventions added only after an incident occurred.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R402, from mental and physical abuse by a Certified Nursing Assistant (CNA B). The incident was reported to the State Agency following a complaint submitted on 11/27/24. The complaint alleged that CNA B had verbally and physically abused R402 by hitting the resident on the hand and calling them 'Grumpy' multiple times. The family member of R402 had placed a camera in the room due to suspicions of abuse, which captured the incident. The video footage showed CNA B entering R402's room, addressing them as 'Grumpy,' and making an intimidating gesture towards the resident, who was observed pulling away from the CNA. R402 was admitted to the facility with a diagnosis of dementia, major depressive disorder, and anxiety disorder, and was receiving hospice services. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of three, signifying severe cognitive impairment. During an interview, the facility's Administrator acknowledged viewing the video footage and confirmed that CNA B was reeducated on communication, company policy for abuse, and quality of care. However, the report does not provide additional information on further actions taken by the facility by the exit of the survey.
Deficiencies in Resident Transfer and Supervision
Penalty
Summary
The facility failed to ensure safe transfer practices for residents, leading to multiple accidents and injuries. One resident, who required maximum assistance for transfers, fell during a toilet transfer when their knee buckled, resulting in a tibia fracture that required surgery. The LPN assisting the resident did not use a gait belt, and the facility's investigation into the incident was inadequate, failing to identify the proper transfer technique or the necessity of using a gait belt. Another resident experienced multiple incidents involving a Hoyer lift, resulting in injuries that required hospital visits. The facility did not conduct thorough investigations into these incidents, and there was a lack of documentation regarding the staff involved and the specific circumstances of the accidents. The facility also failed to ensure that the appropriate Hoyer lift was used for the resident's weight, contributing to the accidents. Additionally, a resident with severe cognitive impairment was improperly transported in a reclining wheeled chair, causing leg pain and distress. The facility's staff did not follow proper procedures for moving the resident, and the incident was observed by the resident's family via Facetime, leading to a police report and emergency department visit. The facility's failure to provide adequate supervision and safe transfer techniques resulted in repeated falls and injuries for another resident with a history of falls and poor cognition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff correctly administered physician-ordered medications to residents, resulting in medication errors for three residents. On one occasion, a nurse mistakenly gave a resident medication intended for another resident, specifically administering Xanax to a resident who did not have an order for it. This error occurred after the nurse had worked a long shift and was preparing medications for two residents simultaneously. The incident was not documented in the resident's clinical record, and the resident was not notified of the error. Additionally, the facility did not provide Incident and Accident reports for all involved residents, specifically lacking documentation for one resident. The Director of Nursing confirmed awareness of the medication errors, which included administering an incorrect medication and dose to another resident on a separate occasion. The facility's policy on medication-related problems emphasizes the importance of following clinical guidelines to prevent such errors, yet these guidelines were not adhered to, leading to the deficiencies observed.
Failure to Identify and Treat Skin Conditions
Penalty
Summary
The facility failed to identify and treat new venous ulcers, ensure physician oversight, and accurately assess a change in skin condition for two residents. Resident #21 was observed with swollen legs and feet, with visible drainage and open areas on the feet, indicating untreated venous ulcers. Despite having physician orders for wound care, there was no documentation of treatment for the feet, and the physician's progress notes did not mention any wounds. The nursing staff, including LPNs and the DON, were aware of the condition but failed to provide appropriate care or documentation, citing the resident's refusal of care as a reason. Resident #12 reported abdominal itching and groin irritation for three weeks, requesting Nystatin powder, which had been used previously for similar issues. Despite informing nursing staff and a doctor, no action was taken, and no orders for treatment were found in the resident's records. Upon assessment, the resident's skin showed signs of irritation, confirming the resident's complaints. The DON was unaware of the issue until informed by the surveyors, indicating a lack of communication and follow-up on the resident's concerns. The facility's policies on skin management and physician involvement were not followed, as evidenced by the lack of documentation and treatment for the residents' skin conditions. The DON admitted to not having a wound nurse or contracting with an outside provider, placing the responsibility on the attending physician and herself. The failure to assess, document, and treat the residents' skin conditions highlights significant deficiencies in the facility's care processes.
Controlled Substances Not Securely Stored Due to Broken Lock
Penalty
Summary
The facility failed to ensure that controlled substances were stored in locked compartments in the 400-Hall, which could potentially affect all residents with prescribed controlled substances in that area. A discrepancy was noted in the count of Klonopin, a Schedule IV anti-anxiety medication, where the count decreased from 25 to 22 without any signature accounting for its administration. Interviews revealed that the lock on the controlled substance box was broken, and although the Director of Nursing (DON) was aware and a work order was put in, the medications were not moved to a secure box. Interviews with staff members, including RN E, LPN A, LPN B, and RN G, indicated varying levels of awareness and communication about the broken lock. RN E was informed by the day shift nurse about the broken lock, and RN G confirmed receiving a report about it. The Maintenance Director confirmed replacing the lock after a work order was created by the DON. The facility's policy requires controlled substances to be stored in a double-locked compartment, which was not adhered to in this instance.
Misappropriation of Controlled Substance in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled substance medication for one resident, identified as R401, who was prescribed clonazepam for conditions including generalized anxiety disorder, dementia with behavioral disturbance, and bipolar disorder. The discrepancy was noted when the controlled substance count sheet for R401's clonazepam showed a reduction from 25 to 22 tablets without proper documentation or signatures accounting for the administration of the medication. The facility's policy on abuse, neglect, and misappropriation of resident property defines misappropriation as the wrongful use of a resident's belongings or money without consent. Interviews with staff revealed that the discrepancy was discovered during routine medication counts conducted by LPN A and RN G. LPN A did not notice the discrepancy during her shift as R401's medication was only administered at night. When the count was off, LPN A and LPN B documented the actual count and notified the DON. RN G, who was involved in the medication count, did not notice the discrepancy until the count was conducted with LPN A. A urine drug test for RN G did not include testing for benzodiazepines, and the facility's investigation into the missing medication was inconclusive, with two clonazepam tablets unaccounted for.
Failure to Timely Identify and Treat Wrist Fracture
Penalty
Summary
The facility failed to identify and treat a wrist fracture in a timely manner for a resident (R701) who experienced multiple falls and made an allegation of abuse. The resident was observed with a cast on his left arm and reported pain when not taking pain medication. The clinical record revealed that the resident had a fracture of the left wrist and hand, and a displaced fracture of the left ulna, diagnosed on 4/10/24. Despite multiple falls and complaints of pain, the facility did not seek timely treatment or diagnostic tests to rule out a fracture until 4/1/24, when an X-ray was finally ordered and confirmed the fracture on 4/2/24. The resident's clinical record showed several instances where the resident fell, complained of pain, and exhibited swelling and bruising on the left wrist. On 2/24/24, the resident alleged abuse, stating he was hit and fell, hurting his wrist. Despite this, the physician did not order an X-ray, citing no palpable pain and normal range of motion. The resident continued to experience pain and swelling, with multiple progress notes documenting these symptoms, but no further diagnostic tests were ordered until the end of March. Interviews with staff and the resident's family member revealed that the resident's wrist was visibly deformed and swollen, and the family member expressed concerns about the lack of timely medical intervention. The Director of Nursing acknowledged awareness of the resident's condition and falls but stated that they followed the physician's orders, which did not include an X-ray. The facility's policy on acute condition changes emphasized the need for detailed observations and timely communication with the physician, which was not adequately followed in this case.
Failure to Evaluate and Assess Pressure Ulcers
Penalty
Summary
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident (R702). R702 was admitted with diagnoses including a right femur fracture and hypertension, and initially had no pressure ulcers. However, on 7/2/23, a wound progress note indicated red, slow-to-blanch, boggy heels bilaterally, and a red, blanching sacrum and coccyx. Despite this, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments or heel lift protectors until 7/12/23. By 7/9/23, R702 had developed a Stage 2 sacrum pressure ulcer and a DTI to the right heel. The physician progress notes from Dr. J and NP K did not mention these pressure ulcers or injuries, and both medical professionals indicated they focused on the resident's primary reason for admission rather than the pressure ulcers unless specifically notified by nursing staff. Interviews with Dr. J and NP K revealed that they relied on nursing staff to notify them of wound issues and typically did not assess or evaluate pressure ulcers unless there was a specific concern such as infection or the need for debridement. The facility's policy on physician services indicated that the attending physician should participate in the resident's assessment and care planning, including monitoring changes in the resident's medical status and providing consultation or treatment. However, this policy was not followed in the case of R702, leading to a lack of proper evaluation and treatment of the resident's pressure ulcers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 996 citations issued within 25 miles in the last 12 months — including the 4 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 Rochester Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bellbrook | 0.9 mi | ★★★★★ | 6 | 0 |
| The Springs At Rochester Hills Rehab And Nursing C | 1.9 mi | ★★★★★ | 27 | 0 |
| Optalis Health And Rehabilitation Of Troy | 2.8 mi | ★★★★★ | 16 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 4.4 mi | ★★★★★ | 13 | 0 |
| Regency At Shelby Township | 4.8 mi | ★★★★★ | 7 | 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.