Notting Hill of West Bloomfield

Inspectors wroteThis citation relates to Intake 2806062 and Intake 2807263. Based on observation, interview, and record review, the facility failed to prevent an injury of unknown origin for one Resident (R65) of four residents reviewed for accidents, resulting in R65 sustaining a right arm fracture during care, with increased pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings Include:On 03/23/2026 at 9:00 AM observed a food item discard date schedule posted on the walk-in cooler (WIC) door which included a 14-day discard for cheeses and pepperoni. During this observation when asked about this policy, the Dietary Manager (DM) L said this is a corporate policy. On 03/23/2026 at 9:06 AM observed a facility container of shredded mozzarella cheese with an attached facility provided date marking sticker indicating prep/open date of 3/21/26 and a use by date of 4/4/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility.

Inspectors wroteThis citation pertains to Intake #2694463. Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), failed to ensure infection control standards and practices were consistently implemented by the facility staff and failed to implement an effective infection control surveillance program. This deficient practice has the increased potential to result the in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility and the spread of infection to residents. Findings Include:On 03/23/26 at 11:50 AM observed a functional hopper in soiled laundry sorting room. When the hopper faucet was turned on, discolored water ran for a few seconds before running clear. [...]

Inspectors wroteThis citation pertains to intake 2793611. Based on observation, interview and record review, the facility failed to honor mealtime preferences for six of eight confidential residents that attended the resident council meeting, resulting in expressed feelings of discontent, isolation from peers and loss of autonomy.

Inspectors wroteThis citation pertains to intake 2741968. Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment throughout multiple resident rooms and hallways affecting multiple residents including R17, R31, R87, R91, R100, R110, R125 and eight of eight residents that attended the confidential group interview.

Inspectors wroteThis citation pertains to Intake 2741968. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 18 residents (R25, R41, R123, R46, R61, R65, R72, R78, R81, R87, R90, R91, R93 and R109) of 19 residents reviewed for abuse/neglect/mistreatment, resulting in pain, missed medication administration, treatments and assessments.

Inspectors wroteThis citation pertains to intake 2679285 and 2741968. Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for four (R43, R44, R87 and R110) of four residents reviewed for medication administration, and five of eight residents that attended the confidential group interview; And the facility failed to ensure wound dressings were identified, assessed, changed per physician orders and/or dated for two (R13 and R112) of three residents reviewed for skin conditions.

Inspectors wroteThis citation pertains to intake #'s 2741968, 2679285 and 2694463. Based on observation, interview and record review, the facility failed to ensure sufficient Nurse staffing levels to meet resident needs for three residents (R13, R48, R74 and R102) and multiple anonymous residents that participated in the group meeting of a total census of 106, resulting in long wait times for staff assistance and delay in medication administration and treatments.

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was assessed for the safe self-administration of medication and to have medication kept at bedside for one (R105) of one resident reviewed for self-administration of medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure acceptable standards of nursing care and services were provided for one (R14) out of six residents reviewed for medication administration.

Inspectors wroteThis citation pertains to Intake 2793611Based on interview and record review, the facility failed to ensure pressure ulcer treatments were ordered, completed as ordered, wound care was provided timely, and accurate skin assessments were completed for two (R2 and R115) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified by the consultant pharmacist and signed by the physician were completed for two (R9 and R19) of five residents reviewed for monthly medication regimen reviews [MMR's].

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that the medication error rate was less than five percent with a percentage of 6.45.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for two (R9 and R19) of five residents reviewed for monthly regimen reviews [MRR's].

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the daily nurse staffing information was accurately posted and updated for each shift. This deficient practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels.

Inspectors wroteThis citation pertains to intake #2574455Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one resident (R701), of two residents reviewed for abuse, resulting in the potential for undetected incidences of abuse.

Inspectors wroteThis citation pertains to Intake 2660427. Based on interview and record review, the facility failed to provide care for a cholecystostomy tube (biliary drainage tube inserted into the gall bladder to relieve symptoms of gall bladder disease) consistent with professional standards and in accordance with Physician orders for one (R704) of one resident reviewed with a cholecystostomy (biliary) tube resulting in a delay of surgical intervention to exchange R704's biliary catheter.

Inspectors wroteThis citation pertains to Intake Number: 2563408. Based on observation, interview, and record review, the facility failed to ensure food in the kitchen was labeled and dated when opened or prepared. This had the potential to affect all residents who eat food from the kitchen.

Inspectors wroteThis citation pertains to intake 1245809Based on interview and record review, the facility failed to prevent excessive tension and tugging of an indwelling urinary catheter for one resident (R702) of two residents reviewed for catheter care, resulting in a penile full thickness urethral tear.

Inspectors wroteThis citation pertains to Intake Number(s): MI00151142, MI00152404 and MI00151259. Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent falls and accidents for three of three residents (R804, R806, and R807) reviewed for accidents, resulting in R806 falling and fracturing both legs, R804 sucking on a bleach sheet, and R807 exiting an alarmed door and going down a flight of stairs.

Inspectors wroteThis citation pertains to intake #MI00151259 Based on observation, interview and record review the facility failed to ensure regularly scheduled/routine bathing was offered for one resident (R802) of three residents reviewed for activities of daily living.

Inspectors wroteThis citation pertains to intake #MI00150658 Based on interview and record review the facility failed to ensure pain medications were refilled timely, pulled from the back-up medication supply for administration and administer pain medications per physician orders for one resident (R803) of two residents reviewed for pain management, resulting in uncontrolled pain and a transfer to the emergency room for pain management.

Inspectors wroteThis citation pertains to intake #MI00151259 Based on observation, interview and record review the facility failed to ensure resident food preferences were honored for one resident (R802) of three residents reviewed for food preferences/palatability.

Inspectors wroteThis citation pertains to intake #' MI00149666, MI00149701, MI00149703 and MI00149863. Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse and neglect by facility staff for two residents (R901 and R902) of five residents reviewed for abuse/neglect/mistreatment resulting in R901 being forcefully slapped in the face by a staff member and R902's lower extremities being wheeled into a medication cart and a metal doorframe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate privacy for Resident Council group meetings and addressing grievances for four of 14 Confidential (C) residents (C-4, C-7, C-8, C-10) reviewed for organized monthly Resident Council meetings.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary homelike environment amongst residential common areas including,the central shower room, first floor dinner, room [ROOM NUMBER] and room [ROOM NUMBER]) resulting in an unkempt environment resulting in potential for resident dissatisfaction with their living conditions and failure to maintain a clean healthcare environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely/completed assessments and investigations into multiple falls, and identify and implement appropriate fall interventions for one (R85) of three residents reviewed for accidents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to consistently ensure sufficient nursing staff was provided for residents who resided in the facility, resulting in verbalized complaints of delayed care and services, lack of supervision of residents with wandering behaviors, and the likelihood for further delayed care and unmet care needs. This deficient practice has the ability to affect all 101 residents in the facility, including resident# (R86).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication storage and labeling for medications and biologicals in one of six medication carts and one of one treatment cart. This deficient practice has the potential to affect multiple residents throughout the facility, including R70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection control practices (hand hygiene) during medication pass and implementation of Enhanced Barrier Precautions (EBP) for one (R60) of one resident reviewed for a urinary catheter, resulting in the potential for cross-contamination and the development and spread of infection and disease.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to address a resident's specific nutritional needs for one (R297) of four residents reviewed for nutritional care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing services met professional standards for medication administration and documentation for one resident (R55) out of one reviewed for self administration. Findings Include: Clinical record review revealed R55 was admitted to the facility on [DATE] with a medical history of hepatitis (inflammation of the liver), hypertension, and diabetes. Psychiatric history included major depressive disorder, bipolar disorder, and anxiety. A Brief Interview of Mental Status (BIMS) score assessed on 11/14/24 scored 14/15 indicating R55 was cognitively intact. On 1/14/25 at 10:48 AM, During initial interview, an observation revealed nine scabbed, red colored blister/lesions on forehead, bilateral cheeks, nose and chin. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure communication devices and services were in place for one (R902) of three residents reviewed for communication, resulting in the potential of unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely toileting/brief care for three residents (R78, R31, and R55) of three reviewed for incontinence care, resulting in the resident being left wet for extended periods.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a physician was notified of a change in condition for one resident (R78) of one resident reviewed for change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative therapy services for one (R25) of one resident reviewed for restorative services and range of motion.

Inspectors wroteThis citation pertains to intake # MI0048767. Based on interview and record review, the facility failed to complete a comprehensive nutritional assessment and ongoing evaluation per physician order for one (R297) of four residents reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate indication for use, ensure non-pharmacologic interventions were attempted and identify behaviors exhibited prior to the administration of as needed (PRN) psychotropic medication (anxiolytic) for one (R85) of six residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain and/or coordinate timely radiology services for an X-Ray for one (R63) of one resident reviewed for radiology/other diagnostic services, resulting in the potential for delayed identification of any abnormalities which may require additional medical/treatment intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure pursuing and administration of the pneumococcal and influenza vaccine for one resident (R3) of five reviewed for immunizations.

Inspectors wroteThis citation pertains to Intake Number(s): MI00147948. Based on interview and record review, the facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer for one (R801) of two residents reviewed for wounds, resulting in a hospital transfer facilitated by an outside provider which resulted in an amputation of R801's left great toe.

Inspectors wroteThis citation pertains to Intake Number(s): MI00147948. Based on observation and interview, the facility failed to maintain a sanitary and comfortable environment in the hallway near the main dining room.

Inspectors wroteThis citation pertains to Intake MI00146159 Based on observation, interview and record review the facility failed to protect the residents' right to be free from depravation of goods and services by a nurse for three (R701, R704 and R705) of three residents reviewed for neglect.

Inspectors wroteThis citation pertains to Intake # MI00144835. Based on interview and record the facility failed to ensure that one Nurse (Nurse A) had an active license to practice as a Licensed Practical Nurse (LPN). Failure to ensure Nursing Staff had a valid, active/current license had the potential to affect multiple residents at the facility.

Inspectors wroteThis citation pertains to intake(s): MI00141604 & MI00142153. Based on interviews and record reviews the facility failed to accurately complete Braden assessments, implement preventive/effective interventions for pressure wounds, Implement wound treatments timely or at all, accurately implement Dietician orders to aide in wound healing, and consistently identified worsening of the wounds for two (R's 502 & 504) of two residents reviewed for wounds, resulting in R502 to have developed multiple wounds which included a Stage 4 sacrum pressure ulcer and a Stage 3 right ear pressure ulcer and for R504 to have developed a Stage 4 coccyx pressure ulcer that contributed to their hospitalization, severe sepsis and death.

Inspectors wroteThis citation pertains to Intake Number(s): MI00139564. This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to determine the root cause of falls and implement effective interventions to prevent falls for two (R26 and R90) of four residents reviewed for accidents, resulting in R26 sustaining a closed right hip fracture femur fracture that required Open Reduction Internal Fixation surgery (a surgery used to stabilize and heal a broken bone) which caused subsequent pain and thoughts of being better off if she was dead.

Inspectors wroteBased on interview and record review the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the ability to affect all 91 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to consistently have an employed Infection Preventionist to properly assess, develop, implement, monitor and manage the Infection Control Program. This deficiency had the ability to affect all 91 residents that resided at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the nursing standards of practice for two Residents (R70 and R19) by not accurately transcribing the physician orders and not priming an insulin pen prior to administration resulting in a Resident receiving incorrect medication dose and the potential for receiving incorrect insulin doses.

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of a pharmacy recommendation after the physician's agreement for one (R55) of five residents reviewed for Medication Regimen Review (MRR).

Inspectors wroteBased on interview and record review, the facility failed to continuously implement an antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for multiple resident at the facility, including R9, of 19 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dining experience with dignity that promoted independence with eating for one of one Resident (R90) reviewed for dignity with potential for frustration, decreased nutrition intake, and weight loss.

Inspectors wroteThis citation pertains to Intake(s): MI00139772 and MI00141293. Based on interview and record review, the facility failed to ensure that a resident was free from neglect by not providing timely assistance from the commode chair after toileting for one (R107) of one resident reviewed for neglect, resulting in frustration and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely fingernail care for one (R9) of two resident's reviewed for Activities of Daily Living (ADLs).

Inspectors wroteThis citation has two Deficient Practice Statements (DPS): DPS #1 Based on observation, interview, and record review the facility failed to follow up timely with the physician for one of one Resident (R35) reviewed for physician orders, resulting in the potential for delay in treatment and further decline in health.

Inspectors wroteThis citation pertains to Intake Number(s): MI00141293. Based on observation, interview and record review, the facility failed to implement interventions, treatments, and assessments for two (R42 & R104) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate catheter care and identify signs of a urinary tract infection (UTI) for one (R63) of one resident reviewed for UTIs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an attending physician was supervising medical care, participating in resident assessments and available for consultation for two (R55, R46) of three residents reviewed for physician services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely laboratory services as ordered by the physician to one (R100) of one resident reviewed for laboratory services. A record review of the Electronic Medical Record (EMR) revealed R100 was admitted to the facility on [DATE], for short-term skilled nursing and rehabilitation after recent hospitalization. R100's admitting diagnoses included sepsis, heart failure, and diabetes. R100 had a Brief Interview for Mental Status (BIMS) score of 15/15, based on the Minimum Data Set (MDS) assessment dated [DATE], indicative of intact cognition. An initial observation was completed on 12/12/23, at approximately 9:55 AM. R100 was observed in their bed. During this observation an interview was conducted. During the interview R100 reported that they have been feeling tired for about ten days. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure radiology/x-ray services were obtained and addressed timely for two (R46 and R9) out of two residents reviewed for radiology services.

Inspectors wroteThis citation pertains to intake #MI00137881 Based on observation, interview, and record review the facility failed to document care concerns and follow the facility's policy for concerns for one (R902) of one resident reviewed for grievances.

Inspectors wroteThis citation pertains to intake #'s MI00138181 and MI00138398 Based on observation, interview and record review, the facility failed to ensure medications were available for administration for two residents (R902 and R903) of two residents reviewed for Nursing standards of practice.

Inspectors wroteThis citation pertains to intake #'s MI00137881 and MI00134566. Based on observation, interview and record review, the facility failed to ensure regular scheduled bathing was provided for one resident (R902) of two residents reviewed for activities of daily living.

Inspectors wroteThis citation pertains to intake # MI00134566 Based on observation, interview and record review the facility failed to ensure treatments for a wound were completed timely per Physicians orders and were appropriately assessed for one resident (R901) of one residents reviewed for wound care.