Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 West Oaks Senior Care & Rehab Center during CMS and state inspections, most recent first.
A resident with traumatic brain injury, quadriplegia, dementia, and a history of falls was sent alone to a medical appointment without staff or family supervision. Staff assumed a family member would accompany the resident, but did not confirm this, and the facility lacked a policy for supervision during appointments. Facility leadership acknowledged the failure to ensure the resident's needs were met during the appointment.
A resident admitted with a history of stroke did not have any Physician or Physician Extender progress notes entered into the EHR for several months. The responsible NP acknowledged not documenting visits, and the DON confirmed that this was not in line with facility policy, which requires timely entry of clinical notes.
Two residents with respiratory conditions had their oxygen equipment improperly stored, with one nebulizer mask left uncovered on a bedside table and a nasal cannula mask found touching the floor. Both an LPN and an RN confirmed the equipment should have been stored in plastic bags when not in use, in accordance with facility policy.
A resident with hemiplegia and moderate cognitive impairment fell from bed and sustained a large hematoma and facial bruising when a CNA, while changing sheets, pulled the fitted sheet to turn the resident, causing the resident to roll out of bed. The CNA did not follow facility policy for safe repositioning, and the DON confirmed that proper procedures were not used.
A resident with moderately impaired cognition eloped from the facility after a security guard allowed him to exit without verifying LOA paperwork. The resident traveled to familiar locations and was found unharmed the next day. The facility lacked a specific LOA policy, contributing to the incident.
A resident with severe malnutrition, bacteremia, and dementia had unstageable pressure ulcers on both heels that were not properly assessed, documented, or treated by the facility. The wounds were only addressed on the day of the survey, despite being present upon admission. The lack of timely care and documentation led to a significant deficiency in the resident's wound management.
Resident Sent Unsupervised to Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with significant medical and cognitive impairments, including traumatic brain injury, quadriplegia, dementia, and a history of falls, was sent alone to an outside medical appointment. The resident required a two-person assist for transfers, used a Hoyer lift, and typically utilized a Geri chair when up. Despite these needs and the usual practice of a family member accompanying the resident to appointments, staff failed to ensure supervision during the appointment. Both family members and staff interviews confirmed that the family was not informed of the appointment and that staff assumed the family would meet the resident at the appointment location. Record reviews and staff interviews revealed that there was no facility policy regarding supervision during medical appointments, and staff relied on assumptions rather than confirmation of arrangements. The transportation company confirmed that the resident traveled alone to the appointment. Facility leadership acknowledged that the resident should not have been left unsupervised and that there was a lack of follow-up to ensure appropriate supervision was provided.
Failure to Timely Document Physician/Extender Progress Notes
Penalty
Summary
The facility failed to ensure that Physician or Physician Extender progress notes were entered into the clinical record in a timely manner for one resident. Review of the electronic health record (EHR) for this resident, who was admitted with a diagnosis including cerebral infarction (stroke), showed no Physician or Physician Extender notes since December 2024. During interviews, the Nurse Practitioner responsible for the resident's care admitted to not providing notes in the medical chart, acknowledging that notes should be entered at the time of the visit. The Director of Nursing confirmed that the facility's expectation is for clinical notes to be written within 24 hours of the visit, and agreed that no such notes were present in the EHR for the resident in 2025 until the issue was identified. Facility policy requires that physician orders and progress notes be maintained in accordance with OBRA regulations and facility policy.
Failure to Maintain Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required respiratory care. During observation, one resident's nebulizer mask was found uncovered and exposed to air on the bedside table, rather than being stored in a protective covering as required. When questioned, an LPN confirmed that the mask should have been kept in a plastic bag. This resident had a diagnosis of respiratory failure with hypoxia and was dependent on supplemental oxygen, and their assessment indicated they were cognitively intact. In a separate observation, another resident's nasal cannula oxygen mask was seen attached to the back of their wheelchair, dangling and touching the floor. A registered nurse acknowledged that the mask should have been stored in a plastic bag when not in use. This resident also had a history of respiratory failure with hypoxia, emphysema, and lung cancer, and was cognitively intact. The facility's policy on oxygen administration and safety required that tubing be stored in a plastic bag or similar device when not in use, which was not followed in these instances.
Resident Fall Due to Improper Positioning During Care
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia and hemiparesis following a stroke, who required partial assistance with bed mobility, fell from bed during care. The resident, who had moderate cognitive impairment, was being assisted by a CNA who, while changing the sheets, pulled on the fitted sheet to turn the resident away. This action caused the resident to roll out of bed and fall to the floor, resulting in a large hematoma and extensive bruising on the face. The resident reported that they were told to roll over and subsequently fell. Review of the facility's policy for turning a resident on their side indicated specific steps for safe repositioning, including the use of proper body mechanics and hand placement. The CNA did not follow these procedures, as confirmed by the DON, who stated that adherence to proper procedures could have prevented the fall and injury. The incident was documented in the resident's medical record and confirmed by interviews with staff.
Resident Elopement Due to Inadequate Supervision and Policy Lapse
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident who exited the facility without staff knowledge. The incident occurred when the resident's assigned nurse was unable to locate him during medication rounds. A search was initiated, and it was discovered that the resident had traveled approximately twelve miles, visiting familiar locations and family members. The resident was eventually found by a family member's acquaintance and transported to a hospital without any visible injuries. The resident, who had moderately impaired cognition and required assistance with ambulation, was able to leave the facility through the front door after a security guard buzzed him out. The security guard did not verify the completion of the Leave of Absence (LOA) paperwork, which was supposed to be completed by the resident's assigned nurse and checked by the security guard before allowing the resident to exit. The facility did not have a specific LOA policy in place at the time of the incident, only an elopement policy.
Failure to Properly Assess and Document Heel Wounds
Penalty
Summary
The facility failed to properly assess and document the bilateral heel wounds of a resident, resulting in the potential for the worsening of the wounds. On observation, the resident was found with loosely wrapped bandages on both feet, revealing black dried scabs on the heels. The feet were dry, cracked, and flaking, with no pressure-relieving devices in place. The bandages were undated and began to unravel when lifted. The Wound Care Nurse (WCN) admitted that the wounds were assessed for the first time on the day of the survey, and the care plan was only revised to include the heel wounds on that same day. Orders for wound care were also placed for the first time on the day of the survey. The Minimum Data Set (MDS) Coordinator had not documented the presence of active pressure ulcers, only the potential for them, due to a lack of supporting documentation. The Wound Care Physician confirmed the presence of unstageable pressure ulcers with dried eschar on both heels, which had not been previously treated or documented properly. The resident had been admitted with severe protein-calorie malnutrition, bacteremia, and dementia, and was severely cognitively impaired, requiring maximal assistance with bed mobility and transfers. Despite these conditions, the skin management care plan did not mention the bilateral unstageable heel pressure ulcers until the day of the survey. The resident's hospital notes had indicated deep tissue injuries on the heels, but this was not reflected in the facility's documentation. The Director of Nursing stated that it was expected for the WCN to assess wounds upon admission and obtain treatment orders, which did not occur in this case. The lack of timely assessment, documentation, and treatment of the resident's heel wounds constitutes a significant deficiency in care.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Great Lakes Crossing | 1.3 mi | ★★★★★ | 8 | 0 |
| Regency Heights-detroit | 1.3 mi | ★★★★★ | 0 | 0 |
| Beaconshire Nursing Centre | 1.3 mi | ★★★★★ | 4 | 0 |
| The Orchards At Redford | 2.5 mi | ★★★★★ | 20 | 0 |
| Hartford Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 23 | 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.