Four Seasons Nursing Center of Westland

Inspectors wroteThis citation pertains to intake 3018809. Based on interview and record review, the facility failed to identify the correct resident for an Intravenous (IV) placement for one resident (R703) out of six reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely complete annual PASARR (Pre-admission Screening and Annual Resident Review - Level I) assessments and review to the appropriate State - appointed authority for six residents (Resident #5, #6, #11, #14, #59 and #117) of six reviewed for PASARR Level I assessments. The Pre-admission Screening/Annual Resident Review (PASARR) in Michigan is a two-step screening and evaluation process. The purpose of the PASARR process is to encourage community care by supporting the placement of individuals with Mental Illness (MI) or those with Intellectual/Developmental Disabilities (ID/DD) in a nursing facility only when their medical needs clearly indicates that the resident requires the level of care provided by a nursing facility. Resident #5On 4/07/26 the medical record for R5 was reviewed and revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply orthotic equipment (hand splints, knee braces, heel lift boots, and elbow extensions) for four residents (R9, R22, R48, and R144) out of four reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain consent and provide risk versus benefits of psychotropic medication use for one severely cognitively impaired resident (R109) of five residents reviewed for unnecessary medications.

Inspectors wroteThis citation pertains to Intake number 2980818. Based on observation, interview, and record review, the facility failed to protect the resident's (R82) right to be free from physical abuse by another resident (R45) out of five reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to timely coordinate with the appropriate State-appointed authority to complete a PASARR (Preadmission Screening and Resident Review) Level II Comprehensive Evaluation (used to determine the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) for one resident (R38) of five residents reviewed for PASARR Level II recommendations.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely appointment of a guardian for one resident (R99) out of one resident reviewed for medically related social services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean privacy curtains for two residents (R13 and R64) of three reviewed for homelike environment.

Inspectors wroteThis citation pertains to Intake: 274990Based on observation, interview, and record review, the facility failed to protect the resident's privacy for four residents (R904, R905, R906, and R907) of four residents reviewed for resident rights.

Inspectors wroteThis citation pertains to Intake: 2789064Based on interview and record review, the facility failed to administer medications properly to one resident (R901) of one reviewed for medication administration.

Inspectors wroteThis citation pertains to Intake 2569649. Based on observation, interview, and record review, the facility failed to protect one resident's right (R703) out of one reviewed to be free from mental abuse and verbal abuse by staff. An allegation of staff to resident abuse involving Staff F and R703 was submitted to the state agency around 7/9/25. On 7/30/25 at 9:45 AM, R703 was observed sitting up in their wheelchair in their room. When the resident was asked about the incident involving Certified Nursing Assistant (CNA) F on 7/9/25, they said the nursing assistant came in that morning to empty my catheter bag. I told them to be sure it was closed because it has been leaking. The nursing assistant got smart with me and said she knew how to do her job. So, I called her a B**** and spelled it out to her. We argued. [...]

Inspectors wroteThis citation pertains to Intake 1246198Based on observation, interview, and record review, the facility failed to apply compression stockings for one resident (R700) out of two reviewed for following physician orders.

Inspectors wroteThis citation pertains to Intake 2564064Based on interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) for one resident (R702) out of one reviewed for pressure ulcers.

Inspectors wroteThis citation pertains to Intake MI0015340. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R903) of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage and discarding of medications in one of eight medication carts affecting three residents (R906, R907 and R908) of three residents reviewed for medication storage.

Inspectors wroteThis citation pertains to Intake MI00153683 Based on observation, interview, and record review, the facility failed to provide nail care to one (R703) of five residents observed for nail care.

Inspectors wroteThis citation pertains to Intake MI00153683 Based on observation, interview and record review facility failed to answer call light in a timely manner for one (R703) of five residents reviewed for timely call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food items were of the proper consistency. This deficient practice had the potential to affect all 9 residents receiving a pureed diet texture.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely repositioning for four dependent residents (R34, R44, R97, R118) of five reviewed for positioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer the correct tube feeding formula for one resident (R119) of four reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent resulting in two medications errors in 32 opportunities for a 6.25% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were dated when opened in two of five medications carts and two of two medication rooms reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices by removing used urinals from overbed tables for three residents (R26, R122, 135) out of three residents reviewed for infection control practices. Findings Include: R26 On 02/10/25 at 9:15 AM, R26 was observed laying in bed watching television and a urinal half filled with yellowish urine sitting on over bed table. The resident was preparing for breakfast. A review of R26's medical record revealed R26 was admitted on [DATE] with diagnoses of atheroscloratic heart disease, muscle weakness, and atrial fibrillation. A review of R26's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental status (BIMS) assessment of 15/15 indicating resident is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for two (R42, R24) of two dependent residents.

Inspectors wroteThis citation pertains to Intake Number MI00149416. Based on interview and record review, the facility failed to address a change in condition in a timely manner for one (R801) of two residents reviewed for changes in condition, resulting in the resident being transferred to the hospital where they were found to have a blood sugar of 1200 (normal range 60-120 mg/dl - milligrams per deciliter), fever, and difficulty breathing requiring mechanical ventilation.

Inspectors wroteThis citation pertains to Intake: MI00147682. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R702) of three residents reviewed for care, when R702 sustained a fall with head trauma and bleeding while taking anticoagulant medication.

Inspectors wroteThis citation pertains to Intakes MI00147560 and MI00147466. Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse, between two residents (R700 and R701) out of three reviewed for abuse. Findings Include: A review of an Incident and Accident (I/A) report for R700 dated 10/10/2024 at 5:19 AM revealed the following, Nursing Description: CNA (Certified Nursing Assistant) reported that resident was wet, and the resident stated that R701 poured water on [them]. Writer asked R701 did [they] pour water on R701, [they] stated, I've been asking (R700) for months to shut the f*** up. Resident Description: Resident stated, R701 poured water on me repeatedly and stated,what are you going to do about this. [...]

Inspectors wroteThis citation pertains to Intake MI00147570. Based on observation, interview and record review, the facility failed to implement a nutritional care plan intervention for one resident (R702) out of one reviewed for nutrition. Findings Include: On 10/23/2024 at 12:48 PM, R702 was observed eating lunch in their room. R702 stated they were making a mess and said they had a method for how to eat their food, which included trying to scoop the food together and take a bite. R702 was observed to have food on their (bib like) towel and the bedside table. Observation of the diet ticket on R702's meal tray stated they were supposed to have a divided plate. R702's food was observed to be on a regular plate. On 10/23/2024 at 12:50 PM, Certified Nursing Assistant (CNA) E was observed removing R702's meal tray. CNA E was asked to observe the meal ticket, as well as the plate R702 was eating off. [...]

Inspectors wroteThis citation pertains to Intake MI00147570. Based on observation, interview, and record review, the facility failed to provide and/or document colostomy care for one resident (R702) out of one reviewed for ostomy care. Findings Include: A review of Intake MI00147570 noted the following, Complainant states that there has been skin breakdown around R702's ostomy because they sit in their own waste for extended periods of time. A review of the medical record revealed that R702 admitted into the facility on 7/23/2024 with the following diagnoses, Dysphagia and Multiple Sclerosis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. On 10/23/2024 at 9:33 AM, an interview was conducted with R702. R702 stated the facility staff do not empty their colostomy as often as they should. [...]

Inspectors wroteThis citation pertains to Intake M100144631. Based on observation, interview, and record review, the facility failed to implement measures to reduce the risk of a fall with injury for one (R701) of five residents reviewed for falls.

Inspectors wroteThis citation pertains to intake MI00142546 Based on observation, interview, and record review, the facility failed to pass and /or date water for five of five residents (R804, R805, R806, R807, and R808) reviewed for hydration. Findings Include: R804 On 3/13/2024 at 11:16 AM, R804 was observed laying in bed. Their water cup was beside them on the nightstand. The water was observed to be dated 3/8/2024. On 3/13/2024 at 11:25 AM, an interview was conducted with Registered Nurse (RN) B. RN B was shown the water cup. RN B stated that the water should be passed at the beginning of the shift and as needed. RN B removed the water from the room. R805 On 3/13/2024 at 12:00 PM, R805's water cup was observed dated 3/9/2024. The water cup was observed sitting in a corner. R806 On 3/13/2024 at 12:01 PM, R806's water cup was not dated. The water cup was half full without any ice. [...]

Inspectors wroteThis citation pertains to Intake MI00143053. Based on interview and record review, the facility failed to implement a baseline care plan related to falls and an indwelling catheter upon admission for one resident (R803) of one reviewed for baseline care plans.

Inspectors wroteThis citation has two deficient practices. Deficient practice statement #1. Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 144 residents who receive meal services (7 nothing by mouth residents, or NPO) out of the facility's total census of 151 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to midigate the spread of COVID-19 per facility policy, and the Centers for Disease Control (CDC) guidance resulting in the potential of transmission of infectious disease, and the development of new or recurring infections potentially affecting all 151 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity during care for one (R27) of eight residents reviewed for resident rights and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise and implement an intervention on the care plan for one resident (R137) from a sample of 10 residents reviewed for care plans following a fall.

Inspectors wroteThis citation pertains to Intakes MI00136173, MI00138504, and MI00138662. Based on observation, interview, and record review the facility failed to provide activities of daily living care (ADLs) for two dependent residents (R9 and R77) of nine residents reviewed for ADL care, resulting in feelings of frustration.

Inspectors wroteThis citation has two Deficient Practice Statements: Deficient Practice Statement #1. Based on observation, interview, and record review, the facility failed to follow speech recommendations for one residemt (R77) out of two reviewed for speech.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply knee braces for one resident (R133) out of two reviewed for range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medications in a safe manner for one sampled resident (R254) of one reviewed for medication storage.

Inspectors wroteThis citation pertains to Intakes MI00138504 and MI00138662 Based on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for two residents (R9 and R116) of four residents reviewed for food palatability, resulting in dissatisfaction during meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living care in a safe manner, for one resident (R701), resulting in a fall from bed with injury of a fractured vertebrae.