Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Westlake Health Campus during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Staff were observed storing multiple food items without required dating or labeling, including expired condiments, boiled eggs, barbeque sauce, cooked turkey breast, frozen chicken, pureed vegetables, and open marshmallows. A cook also observed unsecured CO2 cylinders and dried grease buildup on the mealtime express warmer, with the FSD later noting the concerns had been reviewed with staff.
A resident with fragile skin developed a left forearm skin tear and was observed with foam dressings in place, but the chart had no MD order, no wound documentation, and no physician notification. In a separate event, another resident missed an orthopedic follow-up because nursing and the family did not clarify who would provide transportation, despite the appointment being listed in the record.
A resident with dementia, dysphagia, protein-calorie malnutrition, hemiplegia, and severely impaired cognition was observed in bed while breakfast trays remained untouched and no staff were present to assist with feeding. Ordered Magic Cup supplements were not on the trays, and a CNA stated the resident could not feed herself and needed staff to feed her. The record showed fortified foods and Magic Cup ordered with breakfast and lunch, but the care plan and resident profile did not reflect the resident’s current meal-assistance needs.
A resident with COPD and anxiety was observed receiving oxygen at 2 LPM in the room and common area, and at 2.5 LPM via portable E-tank, but the resident did not know the prescribed amount. Record review showed no current physician order specifying oxygen flow rate and no baseline or comprehensive care plan for oxygen therapy. Staff confirmed the prior oxygen order had been discontinued and no new order or care plan was in place.
A resident at risk for skin breakdown developed multiple pressure ulcers that progressed to infection due to failures in timely and accurate assessment, delayed implementation of wound care interventions, missed wound treatments, and lack of regular provider evaluation. Nursing staff documented wounds inconsistently, and medical providers did not thoroughly assess or direct wound care, resulting in the resident's condition worsening and requiring hospital transfer.
The facility did not consistently maintain infection control surveillance or follow its own infection prevention policy, resulting in delayed treatment and lack of follow-up for two residents with eye infections. Documentation was incomplete regarding the resolution of infections and the need for continued contact precautions, and infection surveillance records failed to accurately track and analyze all cases. Staff interviews revealed inconsistencies in responsibility and documentation practices for monitoring infection outcomes.
A resident with complex medical needs had multiple concerns reported by a family member, including delayed treatment of an eye infection and inadequate hygiene. Although the facility documented these concerns and noted resolutions, staff failed to follow their grievance policy by not communicating the outcomes to the family member who reported the issues.
A resident with a Foley catheter and history of urinary retention exhibited symptoms suggestive of a UTI. Despite a physician order to perform a urine dipstick test if UTI symptoms appeared, the nurse did not complete the test before the resident was taken to the hospital by family and subsequently diagnosed with a UTI. The facility's records showed no documentation that the required urine dipstick was performed as ordered.
A resident who was cognitively intact and dependent for toileting was checked for incontinence by a nurse aide despite clearly refusing the care, as their brief was dry. The aide proceeded based on routine practice, disregarding the resident's expressed wishes, which violated the resident's right to dignity and self-determination as outlined in their care plan and facility policy.
The facility failed to maintain a sanitary exterior dumpster area. Several trash bags were observed on the ground next to the dumpster, with a brown liquid leaking from one of the bags. The DM indicated that the dumpster was probably full, causing staff to leave the bags on the ground, even though it had been emptied that morning.
The facility failed to coordinate behavioral health services for several residents, resulting in unmet mental and psychosocial care needs. Observations and record reviews showed a lack of individualized care plans and targeted behaviors for residents on psychotropic medications. The social worker confirmed the absence of resident-specific interventions, contributing to the deficiency in providing necessary behavioral health care.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's transfer to the hospital. The resident, who needed assistance with daily activities, was transferred due to confusion and agitation. The notification was not sent because the medical record entry did not trigger the required notices.
A resident was transferred to the hospital without receiving a written bed hold notification, as required by facility policy. The resident, who was confused and agitated, was supposed to be discharged home but was instead sent to the hospital. The omission occurred because the medical record entry did not trigger the necessary notifications.
The facility failed to implement an effective antibiotic stewardship program, as three residents were prescribed antibiotics for UTIs that did not meet McGeer's criteria. The interim Infection Control Nurse confirmed the lack of notification to providers and absence of documentation regarding the appropriateness of these prescriptions.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in accordance with professional standards of food service safety during observation of the kitchen. During the initial tour, multiple single portion condiments were found in the reach-in refrigerator with an expired use-by date of 12/25/25. Two bags of refrigerated boiled eggs were observed without a use-by date, and a single-serving container of barbeque sauce had no received or used-by dates. An uncovered cooked turkey breast was observed in a pan without any labeling indicating a cooked date or use-by date, and an opened bag of frozen fried chicken was found in the freezer without a use-by date or received date. Two pans of pureed broccoli and green beans were also observed without labeling, and a bag of frozen chicken breast was open to air and unsealed. Additional kitchen concerns included four portable carbon dioxide containers that were freestanding and unsecured, a pile of single and stale marshmallows in an open container with no dating, and dried grease spillage on the racks and bottom flooring of the mealtime express warmer. The cook stated the expired and unlabeled items would need to be thrown away, that the warmer racks and flooring would need to be cleaned, and that the marshmallows would be discarded. The Food Service Director later reported that the concerns had been reviewed with the cook and that kitchen staff were beginning in-servicing and education on the identified issues.
Failure to Obtain Wound Order and Arrange Transportation
Penalty
Summary
The facility failed to obtain a physician order for a foam dressing applied to a resident’s left forearm after the resident reported that fragile skin caused a skin tear while getting out of bed. The resident was observed with multiple foam dressings on the left forearm, including dressings that were undated and had dried blood showing through, and later with dressings dated on subsequent days. Review of the medical record showed no physician orders for the dressing and no documentation of the skin tear, including no physician notification or assessment of the injury. During interview, the nurse stated there was no physician order for the dressing but that a new dressing had been applied because the prior dressing was soiled. The Director of Health Services also confirmed there was no documentation at the time and no order for the dressing. The facility policy reviewed in the record stated that when a skin tear occurs after admission, an incident entry and assessment progress note are to be completed and the wound is to be reviewed in wound management. The facility also failed to ensure transportation arrangements were provided for a resident’s orthopedic follow-up appointment. The resident and a visitor reported that the resident missed the appointment because no transportation was provided. The medical record showed an order for the orthopedic follow-up and a hospital transition form listing the specialist appointment time. The DHS stated there was a miscommunication between nursing and the resident’s family about who would provide transportation, and the nurse who received the appointment information did not clarify with the family who would be transporting the resident.
Failure to Provide Ordered Supplements and Meal Assistance
Penalty
Summary
The facility failed to ensure nutritional supplements were provided as ordered, failed to ensure timely assistance was provided for meals, and failed to update the plan of care to reflect the resident’s current meal-assistance needs for one resident reviewed for nutrition. The resident was admitted with diagnoses including dementia, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, psychotic disorder with hallucinations, gastroesophageal reflux, cognitive communication deficit, protein calorie malnutrition, contracture to the left hand, and gastrostomy status. The resident was noted to have severely impaired cognition and was dependent on staff assistance for all ADLs. During observations, the resident was found lying in bed and not waking with verbal stimuli while breakfast trays remained untouched and there was no staff present in the room. On one occasion, the tray contained dry rice cereal, sliced banana, yogurt, and coffee, but the ordered Magic Cup supplement was not present; on another occasion, the tray contained fruit cup, peach yogurt, dry rice Krispies, coffee, and two Styrofoam cups, but again the ordered Magic Cup was not observed. A CNA stated the resident could not feed herself and required staff to feed her, and that aides or nurses were responsible for feeding her breakfast. The medical record showed an order for fortified foods and Magic Cup with breakfast and lunch, while a discontinued prior order had included 1:1 assistance with meals. The resident profile did not direct a meal-assistance level, and the care plans had not been modified to reflect the resident’s current assistance needs or the ordered supplements.
Missing Oxygen Order and Care Plan
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident with COPD and an anxiety disorder who was receiving oxygen therapy. The resident was observed in their room and in common areas with oxygen infusing at 2 LPM and, at one point, a portable E-tank was observed infusing via nasal cannula at 2.5 LPM. When asked, the resident stated they did not know how much oxygen they should be receiving. Record review showed the resident’s physician orders did not include an order specifying the liters per minute for oxygen therapy, and the care plan did not contain a baseline or comprehensive plan addressing oxygen use. A nurse stated the resident should be receiving 1-2 liters per minute, then reviewed the record and noted there was no current oxygen order and that one would need to be entered. The nurse also found a prior oxygen order had been discontinued and no new order had been placed. The MDS Coordinator confirmed there was no plan of care for oxygen therapy, and the DHS stated the resident needs a physician’s order and a plan of care to receive oxygen.
Failure to Accurately Assess, Treat, and Monitor Pressure Ulcers Resulting in Infection and Hospital Transfer
Penalty
Summary
A resident with a history of a displaced intertrochanteric fracture of the left femur and osteomyelitis was admitted to the facility and identified as being at risk for skin breakdown due to functional mobility decline and bladder incontinence. Initial assessments, including the Braden scale and MDS, indicated the resident was at risk for pressure ulcers but had no unhealed pressure ulcers at admission. However, within days, the resident developed moisture-associated skin damage (MASD) and bruising on the buttocks, which was attributed to frequent bedpan use and anticoagulant therapy. Despite these findings, there was no documentation of a thorough medical provider assessment of the skin impairments at this stage. Subsequent progress notes and wound assessments documented the development and worsening of pressure ulcers on the resident's buttocks, including the emergence of unstageable wounds with slough and eschar. Physician orders for wound care, such as Triad paste and Medihoney, were issued, but there were missed treatments documented in the medication administration records, including missed applications of Triad and Medihoney, as well as missed doses of Vitamin C due to unavailability. Enhanced barrier precautions to prevent infection were not implemented until several days after the wounds were identified, and care plan updates for the new pressure ulcers were delayed. Throughout the resident's stay, there was a lack of timely and complete wound assessments by medical providers, with nursing staff documenting wounds as present on admission despite conflicting evidence. The nurse practitioner confirmed that they did not conduct thorough wound assessments or participate in treatment planning, instead relying on nursing staff to write and later sign off on treatment orders. The resident's wounds became infected, leading to pain, functional decline, and ultimately an acute care transfer to the hospital. There was no documentation that the development of the pressure ulcers was unavoidable, nor was there evidence of comprehensive provider assessment of the wounds prior to the resident's transfer.
Deficient Infection Control Surveillance and Documentation for Eye Infections
Penalty
Summary
The facility failed to consistently maintain an ongoing infection control surveillance system and did not follow its own policy for the Infection Prevention and Control Program. Specifically, there were multiple instances where residents with eye infections did not receive timely treatment, and there was a lack of documentation regarding the reassessment of infection resolution and the effectiveness of prescribed treatments. For example, one resident with a history of acute and chronic respiratory failure, hemiplegia, and dysphagia was observed with bilateral conjunctivitis. There was a documented delay in the delivery and administration of prescribed antibiotic eye drops, and no follow-up assessment was recorded after the completion of the treatment. Additionally, the infection control surveillance documentation did not indicate whether the infection had resolved or if contact precautions were re-evaluated. Another resident experienced recurring eye infections and was prescribed multiple antibiotics and antifungal medications. Despite the implementation of contact precautions and new medication orders, there was no documentation of reassessment of the infection or the need for continued precautions after treatment completion. The infection control surveillance records also failed to accurately track and analyze all cases of eye infections, as some residents treated for infections were not included in the monthly mapping and analysis. The Infection Control Preventionist (ICP) and Director of Nursing (DON) interviews revealed inconsistencies in responsibility and documentation practices for monitoring infection resolution and discontinuing precautions. The facility's policy required surveillance activities to identify, investigate, control, and prevent the spread of infection, as well as documentation in the residents' electronic health records. However, the infection surveillance program did not reflect increases in eye infections, nor did it document educational interventions for staff when infection rates rose. The ICP stated that only facility-acquired infections were counted, and some ongoing infections were not documented if they carried over from previous months. These actions and omissions resulted in a deficient infection prevention and control program, as evidenced by incomplete surveillance, lack of follow-up, and inadequate documentation.
Failure to Follow Grievance Policy and Communicate Resolutions to Family
Penalty
Summary
The facility failed to follow its own grievance policy regarding the follow-up of concerns raised by a resident's family member. The policy required that all concerns be entered electronically, investigated by the department leader, and that the person reporting the concern be informed of the resolution. In the case reviewed, a family member reported multiple concerns to the social worker and administration, including issues with a delay in treating an eye infection and the resident being left in a dirty nightgown. Although the facility documented the concerns and noted resolutions in their records, there was no evidence that staff followed up with the family member to communicate the outcomes or resolutions of these concerns. The resident involved had significant medical needs, including acute and chronic respiratory failure, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, and required staff assistance for all activities of daily living. Despite the facility's policy and the family member's repeated attempts to communicate concerns, the administration and social services staff acknowledged that they only followed up with the resident, who was her own responsible party, and did not contact the family member who had reported the issues. No further explanation or documentation of follow-up with the family member was provided by the facility.
Failure to Follow Physician Order for Urine Dipstick Testing
Penalty
Summary
A deficiency occurred when a physician's order for urine dipstick testing was not followed for a resident with a Foley catheter and a history of urinary retention, dementia, and benign prostatic hyperplasia. The resident exhibited symptoms including feeling unwell, appearing pale and dizzy, and experiencing chills while eating in the dining room. The family requested the nurse to check for a urinary tract infection (UTI). The nurse contacted the physician, who ordered immediate blood tests, but did not perform the urine dipstick as previously ordered for signs or symptoms of UTI. The nurse stated the intention to complete the dipstick test after returning from a break, but the family took the resident to the hospital before it was done. Medical record review confirmed there was a standing physician order to perform a urine dipstick if signs or symptoms of UTI were present, and to send urine for culture and sensitivity if the dipstick was positive for leukocytes. There was no documentation that the urine dipstick was performed or that urine was obtained for testing as ordered. Interviews with the nurse and the Director of Nursing confirmed the expectation that the order should have been followed, but no explanation was provided for the failure to complete the test prior to the resident's transfer to the hospital, where the resident was admitted with a UTI diagnosis.
Failure to Honor Resident Refusal During Incontinence Care
Penalty
Summary
A resident, who was cognitively intact and dependent on staff for toileting, reported that a nurse aide checked their incontinence brief despite the resident's explicit refusal. The resident stated that their brief was dry and that they did not want to be checked or changed at that time. The nurse aide confirmed that, although the resident declined, they proceeded to check the brief, citing facility training and standard practice to check every resident's brief every two hours. This action was taken even though the resident was able to communicate their wishes clearly and had no behavioral issues. The resident's care plan included interventions to honor their preferences and encourage participation in decision-making. Facility policy also emphasized the importance of respecting resident rights, including dignity and the right to participate in care decisions. The incident was observed and confirmed through interviews and record review, demonstrating a failure to provide dignified care and to respect the resident's right to self-determination.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the exterior dumpster area in a sanitary manner. On the morning of October 7th, 2024, 8-10 trash bags were observed on the ground next to the dumpster, with a brown liquid leaking from one of the bags onto the ground. The Dietary Manager (DM) stated that the dumpster was likely full, leading staff to place the bags on the ground. Although the dumpster had been emptied that morning, the bags had not yet been transferred into it.
Failure to Coordinate Behavioral Health Services
Penalty
Summary
The facility failed to ensure proper coordination of behavioral health services for five residents, leading to delayed and unmet mental and psychosocial care needs. Observations and record reviews revealed that staff were unaware of individualized approaches and targeted behaviors for these residents. For instance, one resident was observed to be confused and difficult to arouse, with a medical record indicating a lack of specific care plans addressing their behavioral health needs despite being on psychotropic medications. The social worker acknowledged the absence of documentation for resident-specific interventions and targeted behaviors. Another resident, with a history of muscle weakness and mental disorders, was prescribed antianxiety and antidepressant medications. However, their care plan lacked targeted behaviors and non-pharmacological interventions, leaving frontline staff without guidance on how to address the resident's behavioral health needs. The social worker confirmed that the resident had refused psychiatric services, and the attending physician was responsible for reviewing medication recommendations, yet no specific behaviors were documented. Additional residents with diagnoses such as dementia, anxiety, and depression were also found to have care plans that failed to identify specific behaviors and interventions. The social worker admitted that the facility used generic physician orders for monitoring residents on psychotropic medications, which were not tailored to individual needs. This lack of resident-specific documentation and interventions contributed to the deficiency in providing necessary behavioral health care and services.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify, in writing, the reason for a discharge to a representative of the State Long-Term Care Ombudsman for a resident who was transferred to the hospital and did not return. The resident, who required assistance with activities of daily living, was initially admitted to the facility and later transferred to the hospital due to increased confusion and agitation. The transfer was not communicated to the Ombudsman as required by federal regulations. The Social Worker indicated that the resident was supposed to be discharged home with family but was instead transferred to the hospital. The way the information was entered into the medical record did not trigger the necessary notifications, resulting in the failure to send notices of bed hold provision and transfer to the Ombudsman. The facility's standard operating procedures require that such notifications be sent, but in this case, they were not completed.
Failure to Provide Bed Hold Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide a written copy of the bed hold notification to a resident or the resident's representative upon the resident's transfer to the hospital. The resident, identified as R40, was initially admitted to the facility and later transferred to the hospital on August 4, 2024, without returning. A review of R40's medical record revealed that there was no documentation indicating that a bed hold notification was provided at the time of transfer. On the day of the transfer, a progress note indicated that the resident was alert and oriented only to themselves, with some confusion and agitation. The resident refused assistance from the Certified Nursing Assistant and expressed a desire not to leave the facility. Despite this, the resident was transferred to the hospital for further evaluation due to increased confusion and agitation, as ordered by the provider. The resident's husband and son were present during this time. The Social Worker (SW A) confirmed that the resident was supposed to be discharged home with family but was instead transferred to the hospital. The omission of the bed hold notification was attributed to the way the information was entered into the medical record, which did not trigger the sending of the necessary notices. The facility's policy requires that written information about the bed hold policy be provided to the resident or their representative before a transfer, but this was not done in this case.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program for three residents reviewed for infections. The review of infection surveillance logs for April, May, and June 2024 revealed that three residents were prescribed antibiotics for urinary tract infections (UTIs) that did not meet McGeer's criteria, a tool used to determine appropriate antibiotic use. Specifically, one resident was prescribed Macrobid, another Bactrim DS, and the third Cephalexin, despite not meeting the criteria for a UTI. There was no documentation in the medical records indicating that the appropriateness of these antibiotics was reviewed. During an interview, the interim Infection Control Nurse (ICN), who also served as the Infection Preventionist, confirmed that the facility followed McGeer's criteria for all infections. However, the ICN admitted that they had not notified providers about residents who did not meet the criteria for antibiotic prescriptions. The ICN acknowledged the need to notify providers and ensure documentation in medical records but was unable to provide additional information or documentation regarding the appropriateness of the antibiotics prescribed to the three residents.
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 973 citations issued within 25 miles in the last 12 months — including the 5 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 Commerce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Neighborhoods Of White Lake | 2.1 mi | ★★★★★ | 0 | 0 |
| The Villa At Green Lake Estates | 4.5 mi | ★★★★★ | 4 | 1 |
| Medilodge Of Milford | 5.8 mi | ★★★★★ | 6 | 0 |
| Maple Manor Rehab Center Of Novi Inc | 6.3 mi | ★★★★★ | 2 | 0 |
| The Orchards At Canterbury On The Lake | 6.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westlake Health Campus.
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.