Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 West Bloomfield Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Implement Fall Prevention Interventions: A resident with a documented fall risk, intact cognition, and significant assistance needs was repeatedly observed sliding down in a w/c, yet ordered fall-prevention interventions such as Dycem and a PT eval for proper positioning were not completed. Nursing notes documented a skin tear under the shoulder blade linked to wheelchair contact, followed by an unwitnessed fall after the resident was seen sitting in the w/c shortly before being found face down on the floor; the resident said she could not stop herself from falling forward, and the call light was inactivated.
A resident with chronic pain and intact cognition had an order for acetaminophen-codeine every 4 hours for pain, supported by a care plan directing staff to administer pain medication as ordered and monitor effectiveness. On one shift, nursing notes indicated the resident was in significant pain because scheduled Tylenol #3 had not been refilled, and the nurse later obtained medication from the electronic backup supply and administered it, after which the resident reported relief. Record review showed the last tablet from the regular pharmacy supply was given at midnight, leaving no doses for the rest of the day, and the electronic backup log showed no tablets removed until after 7:00 a.m., meaning no medication was removed for the scheduled 4:00 a.m. dose. Despite this, the MAR reflected that the 4:00 a.m. dose was administered, with no corresponding entry on the controlled substance log or backup dispensing record, and the DON acknowledged that the nurse did not follow facility policy for obtaining backup medication and documenting when a medication is unavailable and not given.
The facility failed to report allegations of verbal and physical abuse involving two residents to the State Agency. One resident reported being hit and verbally abused by CNAs, while another alleged being slapped by staff. Despite internal awareness, these incidents were not communicated to the SA, violating the facility's policy on immediate reporting of abuse allegations.
A facility failed to report an abuse allegation involving a resident with multiple medical and psychological conditions. The resident threw a metal bar at a CNA and another resident, narrowly missing them. Despite a statement being taken, no further investigation was conducted, and the incident was not reported to the NHA or State Agency, violating the facility's abuse policy.
A facility failed to update interventions for a resident with psychological disorders who exhibited aggressive behaviors, such as banging on walls and slamming doors, causing fear among other residents. Despite being cognitively intact, the resident had a court-appointed guardian and was allowed to leave the facility despite being a threat. Staff reportedly ignored the behaviors, and the Nursing Home Administrator was unaware of the situation.
A facility failed to maintain complete clinical records for a resident with multiple medical and psychological diagnoses, resulting in staff not having access to necessary information for care. The resident, deemed a threat to themselves and others, was allowed to leave without guardian consent. Documentation was not available in the electronic medical record, and a requested review of the soft file was not provided.
A resident fell from their bed and sustained serious injuries after a CNA failed to follow the required two-person assist protocol during care. The resident, who required extensive assistance for all ADLs, was left unattended, resulting in a fall and subsequent hospitalization for a hip replacement and treatment of multiple rib fractures.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure interventions to prevent falls were completed and in place for one resident who had a documented fall risk. The resident was admitted with diagnoses including Neoplasm of Cardia and Neoplasm of Bladder, required assistance with most ADLs, and had a BIMS score of 13 indicating intact cognition. The resident’s fall risk evaluation identified a score of 15.0, with factors including intermittent confusion, use of assistive devices, recent hospitalization, and medication use. The care plan included interventions for fall risk related to weakness, including a Dycem anti-skid pad to the wheelchair and a PT evaluation for proper wheelchair positioning. A physician order was written for PT to evaluate and treat as necessary for proper positioning in the wheelchair. However, the record did not show that the PT/OT evaluation was completed. Nursing documentation described the resident repeatedly sliding down in the wheelchair, with staff frequently readjusting the resident’s position, and noted a skin tear under the right shoulder blade that was believed to correlate with contact from the wheelchair back. The resident later had an unwitnessed fall while sitting in the wheelchair. The resident was found lying face down on the floor next to the bed after having been seen sitting in the wheelchair shortly before the fall. The resident stated she was unable to stop from falling forward out of the wheelchair. Documentation also showed the call light was inactivated at the time of the fall, and the wheelchair was later removed for safety reasons. Interviews with nursing and therapy staff confirmed the Dycem had not been in place at the time of the fall and that the therapy evaluation for wheelchair positioning had not been completed.
Failure to Provide Ordered Pain Medication and Accurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received ordered pain medication, to use the backup medication supply when the primary supply was exhausted, and to accurately document medication administration. The resident, who had diagnoses including muscle weakness and low back pain, was admitted in November 2025 and had a care plan for chronic and acute pain related to arthritis and chronic back and shoulder pain, with interventions including administration of pain medications as ordered and monitoring effectiveness. A physician’s order dated 11/19/25 directed that acetaminophen-codeine 300-30 mg be given by mouth every 4 hours for pain. On 11/27/25, nursing documentation indicated that at the start of a shift the nurse was informed the resident was in pain due to not receiving scheduled Tylenol #3 because the prescription had not been refilled. The nurse documented contacting the supervisor, who in turn contacted the physician for authorization to pull medication from the backup supply, after which the nurse obtained the medication from backup and administered it at approximately 11:30, with the resident later reporting relief of pain. However, the controlled substance log showed that the last pill from the pharmacy supply was administered at midnight on 11/27/25, leaving no remaining doses for the rest of that day. Review of the electronic backup dispensing log showed that no codeine tablets were removed from the backup supply until 7:33 a.m. on 11/27/25, indicating that no medication was removed for the scheduled 4:00 a.m. dose. The November 2025 MAR showed the 4:00 a.m. dose as administered by a nurse, but there was no corresponding documentation on the controlled substance sheet or in the electronic backup dispensing log to support that the dose was removed or given. The DON stated that staff are expected to reorder medications before running out and to use the electronic backup machine and notify pharmacy and the provider if medication is not available, and acknowledged that the 4:00 a.m. dose appeared to have been missed and that the nurse likely made a documentation error by recording the dose as given without having medication available or documented removal from backup, contrary to facility policy on timely medication administration and documentation.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report multiple allegations of verbal and physical abuse involving two residents, R404 and R401, to the State Agency (SA). For R404, an incident occurred where the resident was allegedly hit by a Certified Nursing Assistant (CNA) during a toileting transfer. The resident, who had intact cognition and required assistance for activities of daily living, reported being called derogatory names and physically assaulted by staff. Despite the incident being reported to the Director of Nursing (DON) and a Nursing Supervisor, it was not communicated to the facility's Abuse Coordinator or the SA. In the case of R401, a concern was raised that the resident was slapped by a staff member at the nursing station. The resident, who had a history of muscle weakness and a lumbar vertebra fracture, was unable to provide details about the alleged perpetrator. The family was informed of the incident, and the Administrator was aware of the allegations but did not report them to the SA. The facility's investigation did not find evidence of abuse, but the lack of reporting to the SA was acknowledged as a failure. The facility's policy mandates immediate reporting of all alleged violations involving abuse, neglect, or mistreatment to the SA, but this was not adhered to in these cases. The Administrator and DON recognized the oversight and indicated that unsubstantiated allegations should be reported in the future. The failure to report these incidents highlights a significant deficiency in the facility's adherence to regulatory requirements for reporting abuse allegations.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency within the required timeframe. The incident involved a resident with multiple medical and psychological diagnoses, including multiple sclerosis, schizoaffective disorder, and anxiety, who was cognitively intact but had an active court-appointed guardian. The resident reportedly threw a metal bar at a Certified Nurse Assistant (CNA) and another resident, narrowly missing them. Despite a statement being taken by a charge nurse, no further interviews or investigations were conducted by the facility, and the incident was not reported to the Nursing Home Administrator (NHA) or the State Agency. The facility's policy requires staff to immediately report abuse or suspected abuse to their supervisor, who should then assess the situation and report it to the Director of Nursing and/or Administrator. However, in this case, the NHA was unaware of the incident until informed by surveyors, indicating a breakdown in the reporting process. Additionally, there was no confirmation that the family of the resident who was nearly hit was notified of the incident. This failure to report the incident in a timely manner resulted in the potential for unidentified or continued abuse.
Failure to Update Interventions for Aggressive Resident
Penalty
Summary
The facility failed to implement additional and revised interventions for a resident diagnosed with multiple psychological disorders, including schizoaffective disorder, anxiety, and depression, who exhibited aggressive behaviors. The resident, who was cognitively intact but had a court-appointed guardian, was reported to have been allowed to leave the facility despite being evaluated as a threat to themselves and others. The care plan for this resident, last revised in February 2024, did not include updated interventions for their aggressive behaviors, which were initially documented in October 2020. Interviews with other residents and a family member revealed that the resident's aggressive behaviors, such as banging on walls and slamming doors, were frequent and frightening to those nearby. Staff reportedly ignored these behaviors, and a charge nurse acknowledged that the facility was attempting to evict the resident due to these issues. The Nursing Home Administrator was unaware of these reports, indicating a lack of communication and response to the ongoing disruptive behaviors, which had the potential to exacerbate and further disrupt other residents.
Failure to Maintain Complete Clinical Records
Penalty
Summary
The facility failed to maintain and provide complete clinical records for a resident, resulting in staff and providers not having access to all pertinent information necessary for the resident's care. The resident, who was admitted with multiple medical and psychological diagnoses including Multiple Sclerosis, schizoaffective disorder, and a self-care deficit, was evaluated as a threat to themselves and others. Despite this, the resident was allowed to sign themselves out of the facility without consent from their court-appointed guardian. The care plan indicated the resident was cognitively intact with a BIMS score of 15/15, yet the guardian's consent for Leave of Absences (LOA) was not documented or obtained. During an interview, the Nursing Home Administrator and Social Work Director confirmed the absence of guardian consent for the LOA and acknowledged that documentation of conversations with the guardian existed but was not available in the electronic medical record. The Social Worker mentioned that a soft file containing the resident's clinical records and documentation was not accessible to other staff members. A request for a review of this soft file was made but was not fulfilled by the end of the survey, highlighting the facility's failure to ensure complete and accessible clinical records.
Failure to Provide Required Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the required assistance level for care was provided for a resident, resulting in the resident falling from their bed. The incident occurred when a CNA attempted to change the resident's undergarments without the required second person to assist. The resident, who had diagnoses including Parkinson's disease and required extensive assistance for all activities of daily living, fell from the bed positioned at its highest point, leading to a lateral angulated fracture of the right femoral neck and multiple left rib fractures. The resident was subsequently transferred to the hospital for treatment, including a hip replacement surgery. The medical record and facility documentation indicated that the resident required a two-person assist for bed mobility, transferring, and personal hygiene. Despite this, the CNA proceeded alone, resulting in the resident's fall. The CNA admitted to knowing the resident's care requirements but chose to proceed without assistance, stating it was a personal decision and not due to a lack of staff. The facility's incident report and hospital documentation confirmed the extent of the resident's injuries and the circumstances leading to the fall. Interviews with the CNA, Director of Nursing, Assistant Director of Nursing, and the Administrator revealed that the CNA acknowledged their mistake and took full responsibility for not following the resident's care plan. The facility issued a final written warning to the CNA and provided one-on-one education regarding the incident. The deficiency was attributed to the CNA's failure to adhere to the established protocol for the resident's care, resulting in significant injury to the resident.
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 1,200 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 West Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Notting Hill Of West Bloomfield | 0.1 mi | ★★★★★ | 23 | 0 |
| Marvin & Betty Danto Health Care Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Medilodge Of West Bloomfield | 1 mi | ★★★★★ | 21 | 0 |
| Fox Run Village | 3.6 mi | ★★★★★ | 0 | 0 |
| The Villa At Green Lake Estates | 3.6 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for West Bloomfield Health And Rehabilitation Center.
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.