Inspection Reports for
Notting Hill of West Bloomfield
6535 Drake Rd, West Bloomfield Township, MI 48322, United States, MI, 48322
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Inspection Report — Nov 25, 2025
Complaint Investigation
Date: Nov 25, 2025
Visit Reason
Investigation of a complaint received on 2025-10-31 about failure to investigate injury of unknown origin and failure to provide appropriate care for a cholecystostomy biliary tube.
Complaint Details
Injury of unknown origin: established. Failure to provide appropriate care for cholecystostomy biliary tube: established.
Findings
Two violations were established related to failure to investigate an injury of unknown origin and failure to provide appropriate care for a cholecystostomy biliary tube consistent with professional standards and physician orders.
Deficiencies (2)
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate an injury of unknown origin for one resident, resulting in potential for undetected incidences of abuse.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to provide care for a cholecystostomy biliary tube consistent with professional standards and physician orders, resulting in a delay of surgical intervention and falsified nursing documentation.
Inspection Report — Aug 6, 2025
Complaint Investigation
Date: Aug 6, 2025
Visit Reason
Investigation of a complaint received about catheter care and food labeling.
Complaint Details
Catheter care: violation established. Food labeling and dating: violation established.
Findings
Two violations were established: failure to prevent excessive tension and tugging of an indwelling urinary catheter causing a full thickness urethral tear for one resident, and failure to ensure food in the kitchen was labeled and dated when opened or prepared.
Deficiencies (2)
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to prevent excessive tension and tugging of an indwelling urinary catheter for one resident, resulting in a penile full thickness urethral tear.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure food in the kitchen was labeled and dated when opened or prepared, risking food safety for all residents.
Inspection Report — May 14, 2025
Complaint Investigation
Date: May 14, 2025
Visit Reason
Investigation of complaints received on 2025-05-14 about resident bathing, supervision and accident prevention, pain management, and food preferences.
Complaint Details
Failure to provide scheduled bathing to resident R802: established. Inadequate supervision leading to falls and accidents for residents R804, R806, and R807: established. Failure to administer pain medications timely for resident R803: established. Failure to honor food preferences for resident R802: established.
Findings
Four deficiencies were found related to failure to provide scheduled bathing, inadequate supervision leading to accidents, failure to administer pain medications timely, and failure to honor resident food preferences.
Deficiencies (4)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure regularly scheduled bathing was offered twice weekly to resident R802 as required.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision and effective interventions to prevent falls and accidents for residents R804, R806, and R807, resulting in fractures, ingestion of bleach wipes, and elopement down stairs.
F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to ensure pain medications were refilled timely, pulled from back-up supply, and administered per physician orders for resident R803, resulting in uncontrolled pain and emergency room transfer.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility failed to ensure resident R802's food preferences were honored, including providing double portions and correct meal items at proper temperatures.
Inspection Report — Feb 12, 2025
Complaint Investigation
Date: Feb 12, 2025
Visit Reason
Investigation of a complaint received on 2025-02-12 about resident abuse and neglect.
Complaint Details
Resident R901 was forcefully slapped in the face by CNA A: established. Resident R902 was neglected by Nurse D who pushed their wheelchair into objects and failed to respond: established.
Findings
Two residents were found to have been subjected to abuse and neglect by facility staff. Certified Nursing Assistant A was observed forcefully slapping Resident R901, and Nurse D neglected Resident R902 by pushing their wheelchair into objects and failing to respond appropriately.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: CNA A forcefully slapped Resident R901 in the face, and Nurse D pushed Resident R902's wheelchair into a medication cart and a metal doorframe without addressing the harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in the abuse finding for slapping Resident R901. |
| Nurse D | Nurse | Named in the neglect finding for pushing Resident R902's wheelchair into objects and failing to respond. |
Inspection Report — Jan 16, 2025
Renewal
Date: Jan 16, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to maintain sanitary conditions, inadequate nutritional assessments, insufficient nursing staff, improper medication storage and administration, failure to implement infection control practices, and failure to pursue and administer required vaccinations.
Deficiencies (13)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to maintain sanitary conditions in residential common areas including unkempt floors, dirty shower rooms, and improper storage of personal items.
F 0656 Develop and implement a complete care plan: facility failed to develop a comprehensive nutritional care plan for resident R297 specific to their nutritional needs and risks.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: facility failed to ensure nursing services met professional standards for medication administration and documentation for resident R55.
F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: facility failed to ensure communication devices and services were in place for resident R902, resulting in potential unmet care needs.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: facility failed to provide timely toileting and brief care for residents R78, R31, and R55, resulting in residents being left wet for extended periods.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to notify a physician of a change in condition for resident R78 and delayed treatment for a skin condition.
F 0692 Provide enough food/fluids to maintain a resident's health: facility failed to complete a comprehensive nutritional assessment and ongoing evaluation per physician order for resident R297.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: facility failed to consistently ensure sufficient nursing staff, resulting in complaints of delayed care, lack of supervision of residents with wandering behaviors, and potential for unmet care needs.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; ensure PRN orders are only used when necessary: facility failed to ensure appropriate indication for use, non-pharmacologic interventions, and documentation for PRN psychotropic medication for resident R85.
F 0761 Ensure drugs and biologicals are labeled and stored in locked compartments: facility failed to ensure appropriate medication storage and labeling, including unlocked medication and treatment carts and medications found on the floor.
F 0812 Procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards: facility failed to maintain sanitary conditions in the kitchen including undated food items, improper utensil storage, and accumulation of grease and food debris.
F 0880 Provide and implement an infection prevention and control program: facility failed to ensure effective infection control practices including hand hygiene during medication pass and implementation of Enhanced Barrier Precautions for resident R60 with a urinary catheter.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: facility failed to ensure pursuing and administration of pneumococcal and influenza vaccines for resident R3, and failed to inform resident and family of discontinuation.
Inspection Report — Jan 16, 2025
Renewal
Date: Jan 16, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
Multiple deficiencies were identified including failure to maintain sanitary kitchen conditions, incomplete nutritional assessments, insufficient nursing staff, inadequate supervision of residents with wandering behaviors, incomplete fall investigations, improper medication storage and labeling, delayed radiology services, failure to ensure infection control practices during medication administration, failure to document non-pharmacologic interventions prior to PRN psychotropic medication administration, and failure to pursue and administer pneumococcal and influenza vaccinations.
Deficiencies (9)
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: undated food items in walk-in cooler, scoops and bowls stored inside bins with handles resting in food, and greasy shelving unit with food debris.
F 0692 Provide enough food/fluids to maintain a resident's health: failed to complete comprehensive nutritional assessment and ongoing evaluation for resident R297; nutritional assessment incomplete and not timely despite physician orders.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: staffing levels frequently below facility plan, resulting in delayed care and lack of supervision of residents with wandering behaviors.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: incomplete and untimely fall investigations for resident R85, lack of notification to responsible parties and physicians, and inconsistent implementation of fall prevention interventions.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; PRN orders only used when necessary: resident R85 received PRN anxiolytic medication without documented non-pharmacologic interventions or appropriate indication.
F 0761 Ensure drugs and biologicals used in the facility are labeled and stored in locked compartments: medications found on floor and unsecured medication and treatment carts observed.
F 0776 Provide timely, approved x-ray services or have agreement with approved provider: delayed x-ray services for resident R63 after fall, with no facility policy addressing x-rays.
F 0880 Provide and implement an infection prevention and control program: failure to ensure hand hygiene during medication administration and delayed implementation of Enhanced Barrier Precautions for resident R60 with urinary catheter.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: failure to pursue and administer pneumococcal and influenza vaccines for resident R3 despite consent.
Inspection Report — Nov 18, 2024
Complaint Investigation
Date: Nov 18, 2024
Visit Reason
Investigation of a complaint received on 2024-11-18 about inadequate wound care and sanitary conditions.
Complaint Details
Inadequate wound care for diabetic ulcer: established. Unsanitary hallway odor: established.
Findings
The facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer for one resident, resulting in an amputation. The facility also failed to maintain a sanitary and comfortable environment in the hallway near the main dining room.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to timely treat and properly assess a diabetic ulcer on the left great toe of resident R801, resulting in worsening condition and eventual amputation.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to maintain a sanitary and comfortable environment in the hallway near the main dining room due to a strong, putrid odor persisting for weeks.
Inspection Report — Aug 26, 2024
Complaint Investigation
Date: Aug 26, 2024
Visit Reason
Investigation of a complaint received on 2024-08-06 about neglect in medication administration.
Complaint Details
Neglect in medication administration for residents R701, R704, and R705: established.
Findings
Three residents were found to have been neglected by a nurse who failed to administer medications as documented. Surveillance footage confirmed the nurse did not enter residents' rooms or administer medications as recorded.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: RN B failed to administer medications to residents R701, R704, and R705 as documented, and surveillance showed RN B did not enter their rooms or provide medications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in the neglect finding for failing to administer medications and leaving early. |
Inspection Report — Jun 5, 2024
Complaint Investigation
Date: Jun 5, 2024
Visit Reason
Investigation of a complaint received on 2024-06-05 about nursing staff licensure.
Complaint Details
Employ staff licensed as required: violation established.
Findings
One violation was established for employing a nurse with a suspended license.
Deficiencies (1)
F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws: Nurse A was employed and worked at the facility with a suspended Licensed Practical Nurse license effective 2/3/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Licensed Practical Nurse | Named in the established violation for working with a suspended license. |
Inspection Report — Jan 31, 2024
Complaint Investigation
Date: Jan 31, 2024
Visit Reason
Investigation of a complaint received on 2024-01-31 about failure to prevent and properly treat pressure ulcers resulting in severe harm and death.
Complaint Details
Failure to prevent and treat pressure ulcers for residents R502 and R504: established.
Findings
The facility failed to accurately complete Braden assessments, implement preventive interventions, timely implement wound treatments, and collaborate with the Dietician for wound care, resulting in multiple pressure ulcers and the death of a resident.
Deficiencies (1)
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to accurately complete Braden assessments, delayed implementation of wound treatments, failed to notify the Dietician timely, and did not identify worsening wounds for residents R502 and R504, resulting in severe pressure ulcers and hospitalization.
Inspection Report — Dec 14, 2023
Complaint Investigation
Date: Dec 14, 2023
Visit Reason
Investigation of complaints received regarding neglect, pressure ulcer care, falls, and accident hazards.
Complaint Details
Meal service in Styrofoam containers for R90: established. Neglect leaving R107 on commode chair over an hour: established. Pressure ulcer care failures for R42 and R104: established. Falls due to inadequate supervision and root cause analysis for R26 and R90: established. Failure to follow bed mobility plan causing injury to R55: established. Wheelchair safety device failure for R90: established.
Findings
Four residents were found to have actual or potential harm due to neglect, inadequate pressure ulcer care, failure to prevent falls, and failure to follow care plans. Multiple deficiencies were identified related to resident safety and care.
Deficiencies (5)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Resident R90 was served meals in Styrofoam containers contrary to care plan, causing frustration and decreased nutrition intake.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: Resident R107 was left on the commode chair for over an hour without assistance, resulting in emotional distress and hospital transfer.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Residents R42 and R104 did not receive timely or appropriate interventions for pressure ulcers, including unplugged air mattress for R42 and delayed wound treatment for R104.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Multiple failures including lack of root cause analysis and effective interventions for falls for residents R26 and R90, and failure to follow bed mobility care plan for resident R55 resulting in fractures and injuries.
F 0689 Resident R90's wheelchair anti-roll back device was not functioning and brakes were not engaged, increasing fall risk. The urinal was not placed at bedside as required by care plan.
Inspection Report — Dec 14, 2023
Monitoring
Date: Dec 14, 2023
Visit Reason
Interim inspection to determine compliance.
Findings
Multiple deficiencies were found related to resident care, medication administration, fall prevention, infection control, and laboratory services.
Deficiencies (15)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Resident R90 was served meals in Styrofoam containers contrary to care plan and dignity, causing frustration and decreased nutrition intake.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: Resident R107 was left on the commode chair for over an hour without assistance, resulting in emotional distress and hospital transfer.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: Licensed Practical Nurse L failed to prime insulin pen prior to administration, and a transcription error caused Resident R70 to receive incorrect medication dosage.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Resident R9 was observed with excessively long fingernails despite care plan interventions.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident R63 had no physician orders to monitor percutaneous cholecystostomy tube output and delayed dressing care after hospital readmission.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Resident R104 was admitted with a pressure ulcer that was not treated with physician orders until four days after admission.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Resident R42's specialty air mattress was unplugged all day, causing direct pressure on wound sites.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident R26 sustained a right femur fracture after multiple falls without effective root cause analysis or interventions; Resident R55 sustained a nondisplaced proximal humerus fracture due to staff failing to follow bed mobility care plan.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: Resident R63 had green, viscous urine and foul odor indicative of infection that was not promptly reported or treated.
F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care: Resident R46 had abnormal chest x-ray findings on 9/26/23 but was not seen by a physician until 9/28/23; Resident R55's Durable Power of Attorney reported no physician contact for months.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: Resident R55's Novolog insulin dose was not increased for 53 days after physician approval of pharmacist recommendation.
F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents: Resident R100 experienced missed weekly labs due to abrupt suspension of phlebotomy services by the laboratory provider and lack of facility backup plan.
F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results: Resident R46 had a STAT chest x-ray on 9/26/23 with abnormal findings but no timely physician follow-up; Resident R9 was treated with antibiotics for possible osteomyelitis without confirmatory x-ray due to inability to complete x-ray at facility.
F 0880 Provide and implement an infection prevention and control program: Facility failed to maintain a comprehensive infection control program with consistent infection tracking, trending, and staff education; no Infection Preventionist was employed from March 2023 until September 2023.
F 0881 Designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home: Facility had no Infection Preventionist from March 2023 until RN J was hired in September 2023 and completed training in December 2023.
Inspection Report — Sep 7, 2023
Complaint Investigation
Date: Sep 7, 2023
Visit Reason
Investigation of complaints received on 2023-09-06 about medication administration, bathing, wound care, and grievance handling.
Complaint Details
Grievance documentation failure for resident R902: established. Medication administration failures for residents R902 and R903: established. Failure to provide regular bathing for resident R902: established. Untimely wound care treatment and assessment for resident R901: established.
Findings
The facility was found to have multiple deficiencies including failure to document and resolve resident grievances, failure to ensure medication availability and administration as ordered, failure to provide regular scheduled bathing, and failure to provide timely wound care treatment and assessment.
Deficiencies (4)
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. The facility failed to document care concerns and follow the grievance policy for one resident (R902).
F 0658 Ensure services provided by the nursing facility meet professional standards of quality. The facility failed to ensure medications were available and administered as ordered for two residents (R902 and R903). R902 was not administered Gabapentin on 9/3 and 9/4 due to medication unavailability. R903 did not receive Morphine every four hours as ordered and Hyoscyamine Sulfate was incorrectly transcribed as PRN instead of scheduled.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to ensure regular scheduled bathing was provided for one resident (R902). R902 was scheduled for showers twice weekly but missed multiple showers in June, July, and August 2023 without documented refusals.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to ensure treatments for a wound were completed timely per physician's orders and were appropriately assessed for one resident (R901). No wound care treatments were documented until 12/10/22 for a wound identified on 12/4/22, and several treatments were missed. No medical provider evaluations of the wound were found.
Inspection Report — Feb 8, 2023
Complaint Investigation
Date: Feb 8, 2023
Visit Reason
Investigation of complaints received on 2023-02-07 regarding resident neglect, abuse, and inadequate supervision resulting in resident-to-resident altercation.
Complaint Details
Resident call light taken away and physical abuse by CNA A: established. Inadequate supervision leading to resident-to-resident altercation between R901 and R902: established.
Findings
Two substantiated violations were found: CNA A took away a resident's call light and physically abused the resident; inadequate supervision led to a resident-to-resident physical altercation causing injury.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: CNA A took away resident R905's call light and physically smacked the resident on the bottom, resulting in termination of CNA A.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: The facility failed to provide adequate supervision of residents R901 and R902, resulting in a resident-to-resident physical altercation where R902 punched R901 and caused injury.
Inspection Report — Oct 12, 2022
Monitoring
Date: Oct 12, 2022
Visit Reason
Interim inspection to determine compliance.
Findings
Five medication errors were observed during medication administration for one resident, resulting in a 19.23% medication error rate.
Deficiencies (1)
The facility failed to ensure a medication error rate less than five percent when five medication errors out of 26 opportunities for error were observed for one resident (R43). The errors included omission of Coreg 6.25 mg, Senokot-S 8.6 mg/50 mg, and Systane Ultra Solution 0.4-0.3%, and incorrect dosing of Vitamin E and Biotin supplements.
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